Amnesty International is a worldwide
voluntary activist movement working
for human rights. It is independent of
any government, political persuasion
or religious creed. It does not support
or oppose any government or political
system, nor does it support or oppose
the views of those whose rights it
seeks to protect. It is concerned solely
with the impartial protection of human
rights. Amnesty International s vision
is of a world in which every person
enjoys all the human rights enshrined
in the Universal Declaration of Human
Rights and other international human
rights standards. Amnesty
International undertakes research
and action focused on preventing and
ending grave abuses of the rights to
physical and mental integrity, freedom
of conscience and expression, and
freedom from discrimination
Amnesty International
Acknowledgments
Amnesty International would like to thank
all those who have assisted in preparing
for its 2003 campaign on mental health too many to name, but they know who
they are. We are truly indebted to our
advisory group, Edward Boyne, Dr Justin
Brophy, Christina Burke, Dr Harry Kennedy,
Conor Power, and John Saunders who took
time out of their busy schedules to travel
to Fleet Street, Dublin 2 on a regular basis
over the past twelve months to provide
invaluable information and direction.
In compiling this report, Amnesty
International is particularly grateful to
Dr Joe Fernandez for his willingness to
share his expertise and insight collected
over two decades as Director of the
Programme for the Homeless in
St Brendan’s Hospital in Dublin.
He also provided inestimable assistance
to the author in arriving at the
assessment herein, and bringing
this report to completion.
Amnesty International also conveys
its sincere thanks to Emmet Bergin,
Noeleen Hartigan (Simon Communities),
Bob Jordan (Dublin Simon),
and Mamar Merzouk (Focus Ireland)
for their assistance over the past year.
Author: Fiona Crowley, Policy Officer,
Amnesty International (Irish Section)
Seán MacBride House,
48 Fleet Street, Dublin 2.
Published May 2003
Contents
5
7
10
Preface
11
Chapter 1
15
Chapter 2
20
Chapter 3
23
Chapter 4
Introduction
Methodology
International Standards
• Introduction
• The Right to Adequate Housing
• The Right to Mental Health Care
Homelessness in Ireland
Who are Ireland’s Homeless?
•
•
How Many are Homeless?
•
Mental Illness and Homelessness
Homeless Accommodation
Local Authorities
•
•
Voluntary Service Providers
•
Bed & Breakfast Accommodation
Mental Health Care for the Homeless
Introduction
•
•
De-Institutionalisation and Community Care
•
Homeless People and In-Patient Care
•
Catchment Area Services
•
Specialist Homeless Services
•
Outreach Intervention
•
Dual Diagnosis: Mental Illness,
Substance Misuse & Personality Disorder
34
40
44
48
51
•
Discharge from In-Patient Care
•
Supported Accommodation
•
Support for Voluntary Housing Agencies
•
Homeless Children
Chapter 5
Criminal Justice System
•
Crime and Homelessness
•
Prison Mental Health Services
•
Homeless Ex-Offenders
•
Alcohol and Substance use
Chapter 6
Additional Support Structures
•
Personal Advocacy
•
Family Support
•
Stigma
•
Mental Health Legislation
Chapter 7
Government Planning for the Future
•
Introduction
•
Homelessness Action Plans and An Integrated Strategy
•
National Mental Health Policy Framework Update
Conclusion & Recommendation
Endnotes
Preface
Amnesty International began a campaign in February of this year calling on
the Irish Government to respect its legal obligation under Article 12 of the
International Covenant on Economic, Social and Cultural Rights to provide
the best available mental health care to all. This is part of Amnesty’s
expansion of the range of rights we promote in the national sphere.
We hope that this report, and our 2003 campaign will add to the
national voices calling for immediate and radical change in the way
this marginalised group is treated by the Irish State. What we seek to
contribute is the international human rights perspective on this inexcusable
Government neglect. We earnestly hope that our engagement will afford
the many national non-governmental agencies that have been campaigning
on this issue for years the backup of this simple fact: human rights are
binding rights.
When the Irish Government ratified this Covenant in 1989, it wasn’t just
making vague gestures towards some faraway day when it might consider
placing some importance on economic, social and cultural rights. It bound
itself there and then before the eyes of the world to fully respecting, to the
very best of its ability, these most basic human rights of its population.
5
mental illness
Sadly, the right of Ireland’s homeless population to equal access to the
best available mental health care is even less respected than that of the
remainder of society. This is firmly the responsibility of successive Irish
Governments for whom, it seems, mental health just does not matter,
and homeless people matter even less.
THE NEGLECTED QUARTER
We believe that it is our responsibility to raise public awareness that
human rights are not just about torture and imprisonment - they also
include economic, social and cultural rights. The right to the highest
attainable standard of mental health is one such right, as is the right
to shelter. Often people think that human rights concerns are just about
other people in other countries. Some forget - or others never know that international human rights apply equally to everyone in Ireland.
mental illness
6
If we seek to live in a decent and caring world, the very notion underpinning the
United Nations, we should urge our Government to respect the international
order of human rights. We cannot sit quietly by as the rights of the most
vulnerable in our society are persistently and systematically treated as if they
didn’t exist. We should not allow ourselves to stand in judgement over
countries with human rights abuses without also looking critically at our own.
THE NEGLECTED QUARTER
The Government might continue to tell us that progress is happening, that
reports are being compiled, action plans being developed, and expert groups
convened. But it surely cannot deny that every day, homeless people with
severe mental health problems are being denied basic services. It cannot refute
the manifest truth that the rights of homeless people under this Covenant are
not being respected. Our message to Government is that this situation will no
longer be tolerated. Our challenge to Government is to finally do something
meaningful about it.
Seán Love
Director, Amnesty International (Irish Section)
Introduction
“The term ‘homeless’ refers to individuals who lack shelter, resources
and community ties. A substantial proportion suffer from significant
mental health problems which together with concomitant physical
complaints and disabilities, add to their social disadvantage. For a lucky
minority, an out-of-home experience is a once-off event. For others
it is a long-term experience, compounded by inadequate and
poorly co-ordinated statutory services which are known to exacerbate
individual vulnerabilities.”
Notwithstanding these advances, the above report points to the failure of successive
Irish Governments to meet their obligations under international human rights standards,
and to implement the recommendations of a series of national and international reports
on the mental health services. It highlights the longstanding neglect, inconsistent
service planning and under-funding of the mental health care sector generally, and its
conclusions and recommendations apply equally to the services for homeless people.
Homelessness and mental illness are firmly causally linked. However, the service
provision for homeless people with, or at risk of mental illness, is even more
unsatisfactory. The minimalist, piecemeal, and unintegrated manner of the central
planning and delivery of homeless services to date has resulted in a seriously
inadequate and under-evolved mental health care regime for this vulnerable population.
7
mental illness
Amnesty International (Irish Section) launched a campaign on the rights of people
with mental illness in February 2003, with the publication of a report, ‘Mental Illness:
the Neglected Quarter’,2 outlining its concerns about the mental health services
currently available in the Republic of Ireland (Ireland).3 Much progress, has of course,
been achieved in Irish mental health care in recent years. For centuries, in Ireland as
throughout much of the world, people with mental illness were separated from the
rest of society and placed for long periods in large institutions with little or no
treatment, or worse, with radical and dangerous therapies applied to them.
Today, the situation has much improved with a shift towards community-based
services and greater protection for those in in-patient care.
THE NEGLECTED QUARTER
Dr Joe Fernandez1
mental illness
8
As will be outlined below, the statutory responsibility towards Ireland’s homeless
population is limited, data available on their mental health care needs and service
provision is deficient, there is a dearth of supported residential accommodation,
very few specialised mental health teams are available in larger urban areas,
catchment area services are ill-equipped to provide for smaller urban communities,
and there is little or no follow-up after discharge from in-patient care or from prison.
Amnesty International welcomes the recent adoption of a number of government
homeless strategies and plans, which, if implemented, could significantly improve
mental health care for this vulnerable group; but remains concerned that, without
considerable financial investment and binding statutory obligations, progress will
be neither adequate nor timely.
THE NEGLECTED QUARTER
The burden resulting from the gaps in statutory service provision for homeless people
with, or at risk of mental illness falls on voluntary homeless service providers and on
the wider health and social services, all of which are already under enormous strain.
The consequences impact severely on the quality of life for homeless people with
mental illness. The Simon Communities of Ireland, a voluntary homeless agency has
said: “[we] are extremely concerned at the increase ... witnessed in the numbers of
people who are homeless who are presenting with mental ill health. The lack of access
to assessment and treatment services by people who are homeless further exacerbates
the problem - leaving individuals very vulnerable, and homeless services struggling
to ensure they meet service users’ needs.” 4
Amnesty International acknowledges the dedication of the many thousands of people
caring for people with mental illness throughout the country: carers, psychiatrists,
psychiatric nurses, social workers, care workers, psychologists, psychotherapists,
counsellors and other therapists, hospital administrators, health board workers,
civil servants in the Department of Health and Children, etc., who are serious in their
desire to ensure that the best possible service is provided. Amnesty International also
pays tribute to the non-governmental homeless agencies without which the difficulties
experienced by Ireland’s homeless would be so much worse.
In a national mental health context, the World Health Organisation describes the role
of an international organisation such as Amnesty International, vis-à-vis the national
agencies thus:
“International non-governmental organisations help in the exchange of
experiences and function as pressure groups, while non-governmental
organizations in countries are responsible for many of the innovative
programmes and solutions at the local level. They often play an
extremely important role in the absence of a formal or well-functioning
mental health system, filling the gap between community needs and
available community services and strategies”5
‘Left out in the cold’ Irish Times newspaper 8 February 2002
9
mental illness
“A 22-year-old woman, well-educated but a wanderer and a drifter, is
sleeping rough by the canal in Dublin. She’s in an odd state, obviously in
distress. A concerned passerby stops and speaks with her. The girl is
homeless, hungry, distraught. The passer-by brings her home, gives her
a meal and a bed for the night. The girl seems grateful, but
during the night she tries to kill herself. Her host discovers her within
seconds of losing her life. The girl is brought to the casualty department
of the Mater Hospital. The psychiatrist cannot find a bed for the girl. No
one will take her. She has a southside city address, so on the north side
there’s no hostel place, no outreach programme, no safety net.
Somehow, the hospital manages.Another case: a man in his 20s is
suicidal. He too is found by the canal. He has nowhere to sleep,
no money, no food. He has left an abusive family situation. There is no
“home”. He too is brought into the Mater Hospital casualty unit. The
homeless services don’t have a place for him because,
officially, the man is not homeless. To be defined as “homeless”, you
must have been registered as living in a hostel for the previous three
months. But the health board can’t place him in a hostel if he is not
defined as homeless. It seems to be Catch 22.”
THE NEGLECTED QUARTER
This aim of this report is to raise awareness of the fact that absolute or relative
disregard of the needs of the homeless people with, or at risk of mentally illness is a
serious human rights issue; and that Ireland’s homeless population has the right to the
best available mental health care, and the highest attainable standard of mental health,
which is currently not being respected.
Methodology
mental illness
10
THE NEGLECTED QUARTER
This report compiles recent literature and research on the mental health needs of,
and service provision for, Ireland’s homeless population and is intended to provide
an overview of current concerns and recommendations relevant to Ireland’s binding
obligations under international human rights law. It must be noted that there is distinct
paucity of official data collection and needs analysis available on this subject in the Irish
context. This report was carried out by desk research based on reports sourced mainly
from the Department of Health and Children, and the homeless agencies, Simon
Communities of Ireland and Focus Ireland. It is noteworthy that voluntary homeless
agencies are filling gaps in government policy implementation, not alone in relation
to service provision, but also in research and data collection. Interviews with staff
of homeless agencies, mental health professionals, and family members were
also conducted.
Chapter 1
International Standards
Introduction
Ireland has responsibilities towards everyone in its jurisdiction under international law.
These international obligations exist in addition to those in Ireland’s domestic law and
Constitution and where there is a conflict, at the international level, international law
is superior. Even if international standards are not expressly reflected in domestic law,
they are binding on states once ratified. Ultimate responsibility for compliance with
international law lies with the government, not with individual government departments,
health boards, voluntary agencies or service providers. Each general international human
rights treaty, protects the rights of persons with disabilities, including mental illness,
through the principles of equality and non-discrimination. More specific international
standards exist in relation to people with mental illness.
“At first glance, it might seem unusual that a subject such as housing
would constitute an issue of human rights. However, a closer look at
international and national laws, as well as at the significance of a secure
place to live for human dignity, physical and mental health and overall
quality of life, begins to reveal some of the human rights implications of
housing. Adequate housing is universally viewed as one of the most
basic human needs.”6
Article 11(1) of the International Covenant on Economic, Social and Cultural Rights
(ICESCR), ratified by Ireland in 1989, provides: “The States Parties to the present
Covenant recognise the right of everyone to an adequate standard of living for himself
and his family, including adequate ... housing.” The UN Committee on Economic, Social
and Cultural Rights (CESCR), which supervises compliance with the ICESCR, has noted
11
mental illness
The first principle in any discussion of homelessness, is that housing is a fundamental
human right. Everyone should have access to suitable accommodation, and
homelessness, as the most fundamental violation of this principle, should be eliminated.
The United Nations (UN) has pointed out:
THE NEGLECTED QUARTER
The Right to Adequate Housing
that “the Covenant clearly requires that each State party take whatever steps are
necessary” to fully realise this right.7
mental illness
12
Naturally, the accommodation needs of homeless people with, or at risk of mental
illness must be addressed if their mental health is to be safeguarded. As a 1999 nongovernmental report stated: “It is surely taking de-institutionalisation to an unacceptable
extreme to imply that people who are mentally ill can be cared for
even if they have not been properly housed first.”8
Housing alone is not the solution, as the link between homelessness and other
vulnerabilities is a very complex one. The European alliance of homeless organisations,
FEANTSA notes:
THE NEGLECTED QUARTER
“Housing and homelessness are inseparable. Becoming homeless is
generally the upshot of a series of life events which push some people
into exclusion. But housing is often not their only problem: they also have
health (lifestyle, sickness, dependency, etc.), psychological and social
problems (isolation, loss of self-confidence, depression, etc.) which
mount up into a fast-track to homelessness. ... Unfortunately, few
countries take account of the special needs of the homeless in these
areas. Mostly they stop short at treating homeless people’s problems just
as a housing issue.” 9
The Right to Mental Health Care
International human rights apply equally to homeless people, including the right to
the highest attainable standard of mental health in Article 12 of the ICESCR. The UN
Principles for the Protection of Persons with Mental Illness and for the Improvement
of Mental Health Care (the MI Principles) were adopted in 1991,10 and elaborate the
basic rights and freedoms of people with mental illness that must be secured if states
are to be in full compliance with the ICESCR.11 The right to “the best available mental
health care” is enshrined in MI Principle 1(1), which “includes analysis and diagnosis of
a person’s mental condition, and treatment, care and rehabilitation for a mental illness or
suspected mental illness”. MI Principle 1(2) lays down the basic foundation upon which
states’ obligations are built: that “all persons with a mental illness, or who are being
treated as such persons, shall be treated with humanity and respect for the inherent
dignity of the human person”.
In complying with the ICESCR, Ireland is also obliged to secure for homeless people
“the provision of a sufficient number of hospitals, clinics and other health-related
facilities, and the promotion and support of the establishment of institutions providing
counselling and mental health services, with due regard to equitable distribution
throughout the country”.12 The entitlements under Article 12 “include the right to a
system of health protection which provides equality of opportunity for people to enjoy
the highest attainable level of health”.13
The UN Standard Rules on the Equalisation of Opportunities for Persons with Disabilities
provide: “States are under an obligation to enable persons with disabilities to exercise
their rights, including their human, civil and political rights, on an equal basis with other
citizens.”14 This means that services must not just be made available but that people
are enabled to access them.
Consequently, the significant occurrence of mental illness within the population under
review, places an extensive obligation on the Irish State to take positive measures to
address any gaps in their human rights protection, and in any deficiencies in their
13
mental illness
“The obligation of States parties to the Covenant to promote progressive
realisation of the relevant rights to the maximum of their available
resources clearly requires Governments to do much more than merely
abstain from taking measures which might have a negative impact on
persons with disabilities. The obligation in the case of such a vulnerable
and disadvantaged group is to take positive action to reduce structural
disadvantages and to give appropriate preferential treatment to people
with disabilities in order to achieve the objectives of full participation and
equality within society for all persons with disabilities. This almost
invariably means that additional resources will need to be made
available for this purpose and that a wide range of specially tailored
measures will be required.” 15
THE NEGLECTED QUARTER
Furthermore, in order for Ireland to comply fully with the ICESCR, the UN CESCR says:
mental health care. Failure to do so amounts to non-compliance with Ireland’s binding
obligations under Article 12 of the ICESCR.
mental illness
14
THE NEGLECTED QUARTER
As the UN health agency, the World Health Organisation (WHO) reflects the former’s
understanding of what is meant by “the best available mental health care”. In 2001,
it ran a year-long campaign on mental health, when, for the first time, WHO’s annual
report, World Health Day, and discussions at the World Health Assembly all focused
on one topic, namely Mental Health, thereby revealing the urgency and importance
attached at international level to this subject. The WHO 2001 annual report ‘Mental
Health: New Understanding, New Hope’16 provides a detailed account of what is
expected of all states in their treatment of people with mental illness, and lays down
a comprehensive package of recommendations for states to implement according to
their means. In two years of relative prosperity, little action has been taken in Ireland
on many of the core recommendations of the above report.
Chapter 2
Homelessness in Ireland
Who are Ireland s Homeless?
The United Kingdom’s definition, for example, is significantly wider. It defines a
person as homeless if there is nowhere where they, and anyone who is normally
with them, can reasonably be expected to live, and includes those “threatened
with homelessness”.22
How Many are Homeless?
How many people are homeless in Ireland is a matter of some debate. The most recent
official figures for the total number in Ireland date from 2002, when 5581 individuals
were assessed as being homeless,23 the majority of whom were in the Dublin region.24
It must be emphasised that voluntary homeless agencies, and many involved in mental
health service delivery, believe that the figure would be substantially higher if all
15
mental illness
The statutory definition of homelessness in the Irish Housing Act, 1988 includes people
sleeping rough and those accommodated in direct access hostels, emergency shelters
or in Bed and Breakfast accommodation, but excludes those involuntarily sharing with
family or friends, in insecure accommodation, or living in inadequate or sub-standard
accommodation.21 It also excludes those currently housed but who are likely to become
homeless due to a variety of factors including economic difficulties, or health problems
and other vulnerable groups.
THE NEGLECTED QUARTER
One of the difficulties in determining the number of homeless people throughout
the world is the lack of universal agreement on the definition of the term “homeless”.
A concise definition favoured by some,17 is: anyone who “lacks adequate shelter,
resources and community ties”.18 Dr Fernandez, Director of the Programme for the
Homeless at St Brendan’s Hospital in Dublin, observes: “The term also describes a
population living in a continuum of unsatisfactory accommodation ranging from
cardboard boxes through to unsuitable social housing.”19 His operational definition is:
“heterogeneous groups of individuals ... who, in the absence of a stable base and
supportive social networks, have peripatetic lifestyles characterised by poverty, by
a lack of privacy, possessions and personal relationships, and by a tendency to poor
physical health, psychological distress and psychiatric dysfunction”.20
mental illness
16
categories of homeless individuals were included in official statistical reports.
To date, only those using homeless services, recorded as homeless on local authority
housing lists or are known to be sleeping rough are included. Thus, many individuals
in general and psychiatric long-stay hospital care, or in community-based residences,
or in other such environments; while meeting the criteria for homelessness expressed
in the Irish Housing Act 1988, are not recorded in the official count as being homeless.25
As will be seen below, the same applies to a significant number of prisoners who are
believed to be homeless.
THE NEGLECTED QUARTER
As mentioned earlier, the definition of homelessness varies throughout the world, and
a quantitative international comparison of homeless figures is therefore quite pointless.
Yet, one can look to Northern Ireland, which has a population a third of the size of
Ireland’s, to see that, under its definition, approximately 12,694 households are
considered homeless there.26 Some limited comparison with the UK situation can
be achieved through looking at the numbers of people sleeping rough on the streets.
In November 2000,27 speaking on the results of the June 1999 count of 202 individuals
(the most recently reported discrepant estimate is of up to 312 rough sleepers in
Dublin28), Dublin Simon observed:
“Compared to the number of rough sleepers in cities of comparable size
in the UK, the number of rough sleepers in central Dublin is very high.
According to figures from the UK Government’s Department of the
Environment, Transport and the Regions Rough Sleepers Count of June
1999, there are more rough sleepers in Dublin than in Oxford (52),
Manchester (44), Birmingham (43), Nottingham (31) and Liverpool (30)
combined. According to the UK’s Homeless Network Street Monitor
Count of January 1999, the number of rough sleepers in central Dublin
is more than two-thirds of the number of rough sleepers in central
London (302).”29
A rising number of families are homeless in Ireland - for instance, a recent study of
those in Dublin stated:
“In 1984 there were 37 women with 93 children in hostels in Dublin and
no family was homeless for more than six months (Kennedy 1985).30 By
1999 there were 540 families with 990 children (530 under 5 years of
age) assessed as being homeless in the ERHA region (Williams & O’
Connor, 2000).31 [...] The number of single-parent (usually mother-only)
families with young children who find themselves in the vulnerable
position of homelessness has increased at an alarming rate. The impact
of this disruptive, unstable and often chaotic situation on young lives is
becoming clear from research in various countries”32
The true prevalence of mental illness in Ireland’s homeless population is unknown.
The mental health status or needs of Ireland’s homeless does not form part of the
state’s triennial homeless count.34 In advance of the 2002 count, the Simon Community
commented: “The data will tell us nothing about individuals’ housing need, family status
or age, all of which should be pertinent to planning for housing provision. Additionally
they tell us nothing about routes into homelessness and the types of services people
wish to access. In the absence of this information, both the appropriateness of current
service provision and the planning of new services will continue to occur in a chasm.”35
Policy makers and advocacy bodies must consequently operate on estimates.
According to Dr Fernandez,36 a distinction must be drawn between “mental health
problems” induced by homelessness, and “mental illness” which may be a factor in
becoming or remaining homeless; both of which should be attended to primary care
agents i.e. general practitioners, or by the mental health services. Research suggests
that the experience of being homeless may contribute to anxiety or depressive
illnesses.37 On the other hand, a significant factor in precipitating homelessness
is serious mental illness, and alcohol or drug addiction. It is also accepted that
17
mental illness
Mental Illness and Homelessness
THE NEGLECTED QUARTER
The 2002 official Dublin count recorded 640 families with 1140 children as
being homeless.33
mental illness
18
homelessness may exacerbate a previous or existing mental condition: “There is
evidence that the longer the period of untreated mental illness, the more difficult it is
for people to return to their premorbid degree of well being. The very nature of being
homeless and mentally ill is usually synonymous with being untreated for large tracts
of time.”38
THE NEGLECTED QUARTER
With respect to prevalence rates, Dr Fernandez observes that “estimates vary
depending on one’s definition of homelessness and on other less scientific influences,
shaded by considerations of a political or a campaigning nature”.39 He has concluded:
“Professional working with the homeless on these islands, will generally concede that
25 per cent of this group do not admit to having psychological problems, while 75
per cent do. Of the latter, 42 per cent are believed to have a history of mental health
problems which are a consequence of their social deprivation and homelessness.
The remaining 33 per cent are believed to suffer from severe mental and/or behavioural
disorders which contribute significantly to their homeless state and are exacerbated by it.
What is being described is the position at two ends of a continuum, without being able
to identify the point at which distinctions between these groups get blurred or overlap.”40
The WHO 2001 annual report says, “individuals may be predisposed to mental disorder
because of their social situation and those who develop disorders may face further
deprivation as a result of being ill. Such deprivation includes lower levels of educational
attainment, unemployment and, in extreme cases, homelessness.”41
An Irish study conducted in 1997 assessed the prevalence of chronic mental illness
amongst a sample of 502 homeless persons: 32.5 per cent were deemed to have
depression and 27.6 per cent an anxiety disorder.42 Another report calculated that,
based on the official homeless count,43 there were 1500 people homeless with mental
illness in Ireland in 1999.44 Again, the narrow categories of homelessness included in
the official count must be borne in mind when contemplating these figures.
Dual diagnoses of mental illness and substance misuse is also quite high in homeless
populations. The 1997 study above found that 30 per cent of its homeless sample
misused alcohol while another 30 per cent misused other substances.45
The circumstances of homeless families are unfortunate.46 Studies in other jurisdictions
have found very high levels of mental illness in homeless mothers.47 The children of
homeless families have also been found to have a much higher likelihood of developing
significant mental health problems than the remainder of the population. For instance,
Focus Ireland found that 12 of the 31 children profiled in its study “exhibited signs that
they were likely to present with mental health problems of sufficient severity to merit
referral for psychiatric assessment”.48 It concluded that “the rate of psychiatric disorder
is higher amongst homeless children than that of their housed counterparts”.
THE NEGLECTED QUARTER
The WHO 2001 annual report advises that states should conduct more research
into biological and psychosocial aspects of mental health.49 This should include
epidemiological data collection and evaluation, considered by this WHO report to be
“essential for setting priorities within ... mental health, and for designing and evaluating
public health interventions”. Research into the mental health status of the homeless
community should be undertaken regularly if services are to be planned to meet
their needs.
mental illness
19
Chapter 3 Homeless Accommodation
mental illness
20
Local Authorities
Stable and appropriate accommodation is a prerequisite for sustaining mental health
and for recovery from mental illness. The Irish 1988 Housing Act includes in its
definition of homelessness those living in a hospital, county home, night shelter or
other such institution (see note 22 above). However, Section 10 of the Act imposes only
limited obligations on the housing authority to provide “reasonable accommodation” for
a homeless person. Thus, it may:
THE NEGLECTED QUARTER
(a) make arrangements, including financial arrangements, with a body approved
of by the Minister for the purposes of section 5 for the provision by that body
of accommodation for a homeless person,
(b) provide a homeless person with such assistance, including financial assistance,
as the authority consider appropriate, or
(c) rent accommodation, arrange lodgings or contribute to the cost of such
accommodation or lodgings for a homeless person.
This has been accurately described thus: “The 1988 Housing Act provides an enabling
power rather then a statutory duty. The extent of assistance provided by local authorities
to individual homeless people is left to their discretion and often amounts only to
arranging short-term bed and breakfast accommodation.”50
Voluntary Service Providers
Voluntary agencies, to which local authorities are statutorily empowered to devolve
their housing duty, provide much of the available emergency homeless accommodation.
This is often accompanied by insufficient government financial assistance: “In the
absence of statutory provision the voluntary sector has tried to fill the gap to some
extent although many organisations are struggling financially. While ‘bricks and mortar’
finance is accessible, the task of securing revenue support is a problem which has
yet to be effectively tackled.”51 In 2002, the Simon Community issued the following
press statement:
Bed & Breakfast Accommodation
Since the 1990s, private Bed and Breakfast accommodation (B&B) has been
increasingly used as an alternative to emergency homeless accommodation.
A report by Focus Ireland in 2000 identified 1202 households (individuals, couples
and families of which at least 691 had children), as living in emergency B&Bs in
Dublin in 1999, at a cost £4.7 million (€5.97 million) for that year.54 This report noted:
“Accommodating the homeless in Bed & Breakfasts (B&Bs) is an
unacceptable, unhealthy, and expensive short-term solution to housing
shortage. [...] Unfortunately, our research shows that over the last
decade there has been a substantial rise in the use of B&Bs in Dublin,
and an increase in the time people spend there.”
21
mental illness
In a recent survey of 14 homeless families with 31 children in Dublin in Focus Ireland’s
family transition units, “the women and children had been homeless for approximately
8.5 months on average prior to entering the ... family transition units and intermittently
homeless for 26 months on average before living in the family transition units”.53
The report revealed “predictably high levels of parental stress and high level of mental
health needs for children”. It is of note that none of the parents profiled had ever
accessed the psychiatric/psychology services or seen a community psychiatric
nurse either before becoming or while homeless, but 52 per cent and 29 per cent
respectively, had done so upon entering the unit.
THE NEGLECTED QUARTER
“[D]espite the fact that it is now the second year of (the implementation
of Homelessness - An Integrated Strategy), many projects do not know
what funding they will receive to cover this year’s costs, let alone what
they can hopefully plan to receive for 2003. This precarious position falls
far short of the Government’s originally stated commitment to provide
three year funding for projects. In 2001 over 50 per cent of the essential
running costs of Simon services throughout the country (approximately
E8 million) still had to be met by the generosity of the public through
donations and fundraising.”52
mental illness
22
It continued: “The use of B&B accommodation is unacceptable for a number of reasons
including its inherent lack of stability, its inappropriateness in terms of privacy and social
isolation, its impact on the physical and emotional health of users, and the lack of
appropriate support structures associated with this type of accommodation.” It also
referred to evidence of drug and alcohol addiction, and mental and physical health
difficulties among the homeless B&B population.
THE NEGLECTED QUARTER
Chapter 4 Mental Health Care for the Homeless
Introduction
De-Institutionalisation and Community Care
Over the last three decades, the process of de-institutionalisation has come to
be increasingly implemented in Ireland with a de-emphasis on institutional care
and an emphasis on a community-based model of service provision. This process
was accelerated on foot of a government strategy, ‘Planning for the Future’,56 in
1984. In response to the 1984 strategy, the Simon Community of Ireland published
‘Send them home: Simon’s response to the Government’s report on the Psychiatric
Services’,57 which warned of the dangers of failing to put in place a comprehensive
and well-funded network of community care alternatives when proceeding with this
policy of de-institutionalisation. Its fears would seem to have been realised as
sufficient resources were not made available to ease the transition to community care.
The 2001 WHO annual report, says: “a sound de-institutionalisation process has
three essential components:
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mental illness
According to Dr Fernandez, specialist homeless mental health services should be
provided in urban conurbations where significant numbers of homeless people
congregate. In these circumstances, specialist services would be expected to work in
tandem with mainstream catchment area services and with voluntary service providers,
to meet anticipated needs. In other parts of the country, such specialist services may
not be necessary as mainstream catchment area services should be able to meet
the particular needs of their much smaller number of homeless.55 It is widely
acknowledged that the services for homeless people with mental illness are
seriously underprovided in both contexts.
THE NEGLECTED QUARTER
The quality of mental health service provision for Ireland’s homeless population
is under-researched by central government. Consequently, Amnesty International
has had to rely largely on the reports of voluntary homeless agencies, individual
health boards, non-governmental bodies, and on interviews with service providers,
in particular with Dr Joe Fernandez, Director of the Programme for the Homeless
at St Brendan’s Hospital, in concluding on the availability and accessibility of services
to homeless people.
• Prevention of inappropriate mental hospital admissions through the provision of
community facilities;
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24
• Discharge to the community of long-term institutional patients who have
received adequate preparation;
• Establishment and maintenance of community support systems for noninstitutionalised patients.”58
THE NEGLECTED QUARTER
De-institutionalisation in Ireland has generally failed to live up to this standard.
One report has concluded: “the rise in homelessness from the 1980s has often been
linked to the de-institutionalisation of psychiatric patients into the community. In Ireland
the evidence is less that discharged former long-stay patients became homeless but
rather that the reduction of long-stay beds closed off what in effect was a residual
social accommodation role performed by long-term psychiatric institutions.”59
It has been accepted that the failure to couple the creation of alternative
accommodation with the de-institutionalisation process is at least partially responsible
for the high numbers of long-term homeless persons with chronic mental illness:
“Thus far, policies aimed at dismantling institutions have ensured that
positive bias is exercised in making available such sheltered or
supervised accommodation as exists to the new ‘deserving poor’, mainly
those old, long-stay patients who are deemed capable of being
relocated outside of hospital. Given this, it is felt that many long-term
homeless mentally ill are forced to resort to emergency social
accommodation for their permanent abode. For the latter, remaining
homeless is a decision mediated not by ‘personal choices’ but by a lack
of statutory responses to their need. De-institutionalisation and the
concomitant reduction in bed numbers had led - as elsewhere - to
policies and practices that emphasise preclusive admissions and
accelerated discharges.”60
Homeless People and In-Patient Care
This situation also leads to silting up of bed places much needed by others.
‘We have no beds’ discovered “an increasing number of reports of EHB psychiatric
services which had no beds for patients who were acutely ill and who needed
hospitalisation”.65 The result is that, for many, their right to in-patient care is seriously
compromised. In response to the Inspector’s observation above, a mental health
support organisation, Schizophrenia Ireland, commented: “While we are aware that
some service provision has been made there is a need to ensure that this problem is
addressed urgently to ensure that people who are homeless do not end up in the prison
population or are not receiving adequate mental health care supports”.66
Another consequence revealed in ‘We have no beds’ was the emergence of
“a system of borrowing beds for short term purposes from one service by another”,
an arrangement described as “unsatisfactory for patients, representing poor quality of
service delivery to acutely ill persons”. It also concluded: “Because of the pressure on
25
mental illness
The Inspector of Mental Hospitals has also remarked on this problem in his report for
2001 as follows: “Time and again, the Inspectorate has been struck by the number of
current psychiatric in-patients who are homeless and are accommodated in acute or
long-stay hospital wards despite being suitable for community residential placement.
There is hardly a service in Ireland where this is not a current issue.”63 Failure to
provide alternative supported accommodation for those who are consequently
compelled to remain in hospital, does not comply with their “right to be treated in
the least restrictive environment”.64
THE NEGLECTED QUARTER
It is accepted that homeless people in need of acute psychiatric care require longer
in-patient stays than their housed counterparts,61 but insufficient in-patient facilities
are available to them throughout the regions. Conversely, due to the failure to
implement the full range of community-based services recommended in ‘Planning for
the Future’, an unknown proportion of acute beds remain inappropriately taken up by
long-stay patients who have nowhere else to go. Because homeless services are
widely deficient, with a particular shortage of supported residential care
accommodation; homeless people were discovered to make up to one third of all
persons inappropriately occupying acute psychiatric beds in the ERHA area in a 1999
report, ‘We have no beds’.62 Many of the individuals in question were considered
suitable for community-based residencies but appropriate facilities were reportedly
not available.
acute beds in some areas it was often not possible to offer respite care for patients with
serious mental illness in an effort to avoid relapse.”
mental illness
26
Catchment Area Services
THE NEGLECTED QUARTER
Currently, mental health, alcohol, and drug-related problems of homeless people cannot
be effectively met by mainstream catchment area services, as there are far too many
barriers to accessing these services. Firstly, it is well recognised that homeless people
pay less attention to health care than they do to their basic requirements of food,
shelter and physical safety, so many are unlikely to present at primary care level to a
General Practitioner.67 Secondly, the general mental health services are already
overstretched throughout the country. Thirdly, specialist services such as alcohol and
drug addiction services are inadequately provided. Fourthly, despite the significant
occurrence of dual diagnosis of mental illness and substance misuse, many homeless
people fall between the dedicated services for these conditions (see below). Finally,
mainstream services are reported to be resistant to accepting homeless persons:
“The inflexibility of delivery in conventional psychiatric services and the negative
attitudes of mental health professionals along with negative stereotypes, are believed to
compound the problem. A proportion of the homeless mentally ill have a forensic history.
This, together with a tendency to abuse alcohol and drugs, apparently does not endear
this group to the general psychiatrist”.68
Considerable difficulty arises for homeless people in accessing mental health care due
to the sectorisation of services into catchment areas. Whereas Amnesty International
understands that individual service providers are often flexible about these
arrangements, the fact remains that strictly speaking, homeless people in need of
mental health care are expected to return to their previous places of residence for such
treatment as may be needed; effectively leaving many without a service. It is reported
that: “Sectorisation has [also] led to staff generally not trained to meet and understand
the needs and special requirements of some people homeless.”69 The difficulties in
accessing mainstream services have also lead to increased pressure on the Programme
for the Homeless at St Brendan’s Hospital described below.
The need for catchment area services to adapt, in line with recommendations made
by the Royal College of Psychiatrists in 1990 and 1991, was pointed out to the
Department of Health and Children in 1993.70 Regrettably, matters do not appear to
have progressed in the Dublin area. The impact of the recommendations of the Royal
College of Psychiatrists on other regions in Ireland has yet to be assessed.
Specialist Homeless Services
Funding was to have been provided to the ERHA this year to enable an additional
Consultant-led team to be established to provide an additional service to homeless
persons with mental illness. While a Consultant has been appointed, some uncertainly
remains at the time of writing about the status of the promised funding for the team.
Some other local planning for specialised services is evident; the Inspector of
Mental Hospitals remarks in his report for 2001: “Plans by the Southern Health
Board to establish a consultant-led psychiatric programme for the homeless with a full
multi-disciplinary team working closely with the Simon Community was welcomed.”74
This programme has not yet been provided.
27
mental illness
Specialist services are generally unavailable in Ireland. In Dublin where it is estimated
that 75 per cent of homeless people live,72 there is one specialist service, a Programme
for the Homeless, operating from St Brendan’s Hospital, which is also the only such
service in the country. This service was established by Professor Ivor Browne and
Dr Fernandez in 1979, and a Day Centre was subsequently provided. Currently, the
Day Centre is located at Usher’s Island, and the Programme has three supported
housing units throughout the city. In 1983, its Director observed that “in time there
is likely to be a greater demand for this type of facility as we are forced to confront
the inevitable ageing of those able bodied mentally ill who, devoid of family supports,
were placed outside of hospital during the rush to community care.”73 No further support
programmes were subsequently put in place; and the pressure on the Programme at
St. Brendan’s Hospital is enormous, as it is now expected to function as a regional
centre, despite being poorly resourced with respect to necessary multidisciplinary
staff e.g. psychologist, social worker and clerical staff. Its 16 in-patient beds, intended
for acute care, have been completely blocked by long-stay patients due to a lack
of community-based residential facilities, and the service is continually under
intolerable strain.
THE NEGLECTED QUARTER
Mental health services for the homeless should be available within each catchment
area in larger cities, where the majority of the homeless are concentrated and
should possess certain essential features: “Adequate, comprehensive and accessible
psychiatric and rehabilitative services must be available and assertively provided.
Services must provide outreach contact for the mentally ill in the community, whether
domiciled, living on the streets or living in shelters. Psychiatric assessment and
evaluation are required, as is crisis intervention and hospitalisation, when necessary.”71
Outreach Intervention
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28
A 24-hour psychiatric crisis intervention service, as available in other jurisdictions,75
has not been made available in a comprehensive or consistent fashion, despite plans
do so for every sector in the 1984 strategy. While back-up facilities and services are an
essential prerequisite, an outreach component for crisis intervention is considered vital.
One of the findings of ‘We have no beds’ was that: “Community-based, emergency
out-reach, 24 hour, seven-day-week, crisis intervention services were generally
unavailable.”76 The result is that at weekends and at night many people are
inappropriately admitted instead to acute psychiatric units. Others may not be
detected by the mental health system at all, but may become caught up in
the criminal justice system instead (see below).
THE NEGLECTED QUARTER
Dual Diagnosis: Mental Illness, Substance
Misuse & Personality Disorder
Many homeless people with a dual diagnosis of mental illness and drug or alcohol
misuse find themselves without a service, since existing services consider themselves
to be either psychiatric services or addiction services, with poorly defined collaborative
functions. According to Dr Fernandez, “the most difficult and deprived group of
dually-diagnosed individuals are those who abuse alcohol and/or other psychoactive
substances and who also suffer from a severe psychiatric disorder”.77 He further
underscores the vulnerability of homeless dually diagnosed individuals by emphasising
that: “in this group, homeless operates metaphorically as yet another diagnosis of
morbidity which confers upon (its members) the greatest amount of handicaps.
Thus, homeless dually-diagnosed individuals have three distinct and interactive
problems, leading to further physical and mental health problems including cognitive
impairment which is now increasingly recognised as a significant factor which
contributes to the constricted adaptive capabilities of homeless dually-diagnosed
individuals”.78 What is required is the development of a programme to deal with
homeless individuals with a variety of problems: “a comprehensive and seamless
system of care, that integrates and co-ordinates interventions in mental health,
addiction, health, welfare and housing services.”79
In discussing the implications of the Mental Health Act, 2001 on homeless populations,
Dr Fernandez stated as follows: “Our new Mental Health Act explicitly excludes
Personality Disorder from the definition of mental disorder. In the absence of mental
illness, significant mental handicap or severe dementia, it is highly unlikely that
Discharge from In-Patient Care
Follow-up for homeless people after discharge from in-patient psychiatric care
is often neglected:
“There is little or no follow-up of patients after discharge from in-patient
care. In ‘Planning for the Future’, the 1984 report by the Department of
Health’s on the future of the psychiatric service, there is a commitment
to ‘continuity of professional responsibility running through the different
treatment services provided by the psychiatric team.’ The reality as
experienced by the Simon Community is that there is no follow-up. If the
person fails to turn up at the clinic, no follow-up action is taken.” 82
29
mental illness
“Another problem is thrown up by homeless individuals who suffer from
mild intellectual disabilities and from mental illness; who may or may not
have a personality disorder; who abuse alcohol and/or other
psychoactive substances and who display cognitive impairment and
dysfunctional behaviour. While any single aspect of their cumulative
indisposition may not be significant to secure admission for in-patient
treatment - when warranted; their combined disability may be far greater
than the sum of its parts and may be consigned to out-patient
management, in insecure accommodation in the community, by
untrained carers and in uncertain circumstances.”81
THE NEGLECTED QUARTER
individuals with personality disorder will either be admitted to psychiatric hospitals
voluntarily or be detained involuntarily. Unless appropriate alternatives are provided to
contain the predictable deviance displayed by some members of this group, the onus
for the management of homeless individuals with significant personality disorder is likely
to fall on: (a) untrained care-staff in the voluntary sector who service the majority of
hostel and night-shelter beds in the community or (b) on the criminal justice system.
In the former event, voluntary agencies will need to be provided with considerable
support in their endeavours.”80
mental illness
30
THE NEGLECTED QUARTER
Others may be discharged directly into the care of homeless emergency shelters
operated by voluntary agencies,83 which are not therapeutically appropriate for people
with mental illness: “The practice of directly discharging people who are without
permanent accommodation from hospitals, including psychiatric hospitals, to emergency
shelters for homeless people, has been documented by the Simon Community as long
ago as 1992.84 Today this modus operandi is more common and is causing greater
problems than ever before.”85 Another voluntary homeless service has reported a similar
experience: “Inappropriate discharge form psychiatric hospitals and inadequate care in
the community continue to be a problem. Centrecare has worked with a number of
people who have been discharged from hospital into the care of homeless services
without any back-up medical support.”86 It is unclear whether the discharging services
referred to, released the patients in question to the care of shelters in which they were
resident prior to their admission, or into shelters where they were not previously
resident. One way or the other, this practice illustrates significant lacunae in aftercare,
the pressures on existing services, and the deficit in supported accommodation; all
of which need to be immediately addressed by the government authorities.
The government has acknowledged the above practice in its 2002 ‘Homeless
Preventative Strategy’, wherein it states: “There is also evidence of prisoners and
hospital patients being discharged directly into services for homeless persons and of a
continuous link between homelessness, prisons and psychiatric hospitals.”87 Amnesty
International welcomes the publication of this Strategy, which is directed at adults
leaving institutional care. However, it remains to be seen how its recommendations
will be implemented, and how the programme for monitoring and evaluating the
performance of the various government departments and health boards will be adhered
to. There is no express provision for an increased number of supported housing units to
receive homeless people with mental illness who are discharged from institutional care.
Its recommendations in respect of follow-up after discharge through homeless
multidisciplinary teams would not appear to have any relevance to many of the
catchment area services where such teams do not exist.
Many of the actions specified in relation to discharge from psychiatric care are
restatements of existing policy, which have never been properly implemented. For
example, it recommends that every patient “will have a formal and written Discharge
Policy”, an instruction given in the government 1998 ‘Guidelines on good practice’.88
There is as yet no evaluation of how this recommendation is being adhered to
in practice.
The Strategy recommends that “records will be kept of the number of patients being
discharged and the type of accommodation”. The Programme for the Homeless at St
Brendan’s Hospital devised its own ‘Pre-Discharge Checklist’ with a set of practical
instructions and safeguards in 1979. The Department of Health and Children issued
an identical checklist in 1985, and another similar checklist in 1987 advising all
services to communicate with the Directors of Community Care in a prescribed
manner when discharging homeless patients.89 There is no evidence that the latter’s
recommendations are being complied with.
“In the European context Ireland is exceptional in the undeveloped
nature of its services to mentally ill people who are homeless. In
particular supported housing is a neglected and under provided area in
Ireland, with less than 200 units of supported accommodation provided
for mentally ill and homeless people, the great majority of these through
the voluntary sector. Health boards do provide some supported
accommodation for people who are mentally ill in the community but this
is mostly for compliant groups. Those who are homeless, who are
generally seen and treated across the system as a non-compliant group,
are not provided for.”93
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mental illness
While there is a shortage of community-based residential facilities and hostels
throughout the mental health service,90 the deficit in such supported housing for
homeless people is particularly worrying. For the many homeless people with mental
illness who are incapable of unassisted independent living, but not in need of in-patient
care: “An adequate number of graded, step-wise community housing settings (with
differing degrees of support) must be established.91 [...] Many housing settings that
require people to manage by themselves are beyond the scope of some people who
are chronically mentally ill.”92 Yet, there is a glaring mismatch between the number of
graded supported housing units and homeless people suitable for such placement.
The Simon Community of Ireland has noted:
THE NEGLECTED QUARTER
Supported Accommodation
A report commissioned by Simon concluded: “There is a critical shortage of necessary
supported housing and community supports for people with mental ill health. ...this
remains the biggest problem for homeless service providers.”94
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32
A recent New York study indicates that the placement of homeless individuals with
severe mental illness in “supportive housing” is associated with a substantial reduction
in homelessness, a decreased need for homeless shelters, significant reduction in
psychiatric hospitalisations and the length of stay per hospitalisation, and significant
reduction in time spent in prison.95
Support for Voluntary Housing Agencies
THE NEGLECTED QUARTER
As mentioned above, the burden of sheltering homeless people with significant mental
health problems, rests substantially with voluntary agencies and is exacerbated by the
failure of the mental health services to provide supported accommodation through the
mental health system. The in-house care support available to voluntary homeless
shelters is also inadequate,96 consequently: “Homeless services, which are not
specialists in mental health, are attempting to meet the needs of people with severe
and chronic mental ill health who are without other housing or support options.”97
The discharge of patients directly into the care of homeless agencies has been
described earlier.
Homeless Children
Amnesty International is concerned that Ireland does not comply with its international
obligations in its treatment of homeless children with, or at risk of, mental illness under
the UN Convention on the Rights of the Child. This Convention provides “the right of
the disabled child to special care and ... the extension, subject to available resources,
to the eligible child and those responsible for his or her care, of assistance ... which is
appropriate to the child’s condition ...”.98 The UN Committee on the Rights of the Child,
in its last report on Ireland in 1998, stated particular concern about the incidence of
child homelessness in Ireland. Focus Ireland, has highlighted the problem of child
homelessness in Ireland,99 and the particularly high rate of homelessness of children
once they leave the state’s residential care.100
Research into the circumstances and mental health needs of children who are
homeless, or at risk of homelessness, is very poor.101 For instance, the homeless agency,
Focus Ireland has found “an absence of an adequate database on young people in the
care of health boards and on leaving health board care”.102 Of course, this is true of
children in Ireland generally:
“The absence of epidemiological information relating to children’s mental
health on a national basis is a significant limitation in our current system.
No routine information system captures information on children’s mental
health problems, with the exception of the national psychiatric in-patient
reporting system, which provides information on children admitted to
psychiatric hospitals. However, since mental health problems in children
rarely require admission, this source of information is of limited value.
A highly developed information system is required, in order to underpin
approaches to quality assurance and evaluation of mental health
Mental health services for children generally are quite inadequate, and those for
adolescents almost non-existent.104 The aforementioned UN Committee report
said that it was “concerned about the lack of a national policy to ensure the rights of
children with disabilities and the lack of adequate programmes and services addressing
the mental health of children and their families.”105 A ‘Youth Homelessness Strategy’
was published by the Department of Health and Children in 2001, the aim of which
is to “reduce and if possible eliminate youth homelessness through preventative
strategies and where a child becomes homeless to ensure that he/she benefits from a
comprehensive range of services aimed at reintegrating him/her into his/her community
as quickly as possible”. However, it provides little in the nature of tangible commitments
or timeframes, other than an instruction to each Health Board to devise a “two-year
strategic plan to address youth homelessness in line with specific actions”.
33
mental illness
identify risk factors and risk groups.”103
THE NEGLECTED QUARTER
prevention and treatment services, to monitor trends in incidence, and to
Chapter 5 Criminal Justice System
mental illness
34
Crime and Homelessness
THE NEGLECTED QUARTER
A 2002 study, ‘Crime and Homelessness’, concluded that “periods of imprisonment
can indeed lead to homelessness, [and] homelessness can also lead to imprisonment”.106
It observed: “There has been little research in Ireland on the complex relationship
between homelessness and crime or on the difficulties and problems faced by offenders
on leaving prison.” It noted that Irish prison statistics yield little information on the
number of prisoners who are homeless.107 Without this sort of information, it would
seem difficult to devise individual sentence and release plans as is the duty of the
prison authorities. The report noted however:
“Recent profiles of male prisoners in Mountjoy prison in Dublin by
O’Mahoney (1993, 1997)108 indicate that 3 per cent and 7 per cent
respectively of the sample populations were homeless. These figures are
considerably lower than those found in comparative studies from the UK.
A recent snapshot survey of the incidence of homelessness among male
and female prisoners in Mountjoy Prison and the Dochas Centre
respectively conducted by PACE in 2002 shows the incidence of
homelessness to be closer to Taylor and Parrot’s (UK) estimate than
O’Mahoney’s. The PACE survey109 found that 33 per cent of all Irish
female prisoners in the Dochas Centre will be homeless on release from
prison and 35 per cent of men reported that they will not have
accommodation upon their release ....”
It nevertheless found that significant numbers of homeless people with mental illness
end up in prison because of public order or nuisance offences, often related to their
homelessness and mental health or addiction problems.110
Prison Mental Health Services
The 2001 WHO report recommends that “policies should be put in place to prevent
the inappropriate imprisonment of the mentally ill and to facilitate their referral or transfer
to treatment centres instead”.114 In this regard, Amnesty International welcomes the
publication of the Criminal Law (Insanity) Bill, 2002. While the stated purpose of the
Bill is to reform the law on ‘criminal insanity’ and ‘fitness to be tried’; to bring it into
line with the jurisprudence of the European Convention on Human Rights, Amnesty
International shares the concerns of other national organisations that the diversion
scheme offered by this legislation will impossibly add to the demands on existing
services, unless accompanied by significant expansion of, and capital and revenue
investment in, the appropriate psychiatric facilities and manpower.
35
mental illness
Secondly, where a person’s primary reason for the commission of a relatively minor
crime is mental illness, proper mental health care should be afforded to them, not
imprisonment. ‘Crime and Homelessness’ advises: “There needs to be a review of the
use of custodial sentences as part of our judicial system for people who are homeless.
Committal to prison should be viewed as a ‘punishment of last resort’.” This is in line
with relevant international human rights standards.
THE NEGLECTED QUARTER
This is of concern in two respects. Firstly, the mental health services available within
the Irish prison system are most unsatisfactory. The report of a government-sponsored
review in 2001 noted “many deficiencies and shortcomings”, and “long-term under
resourcing of prison health care services”.111 For prisoners in need of in-patient care,
Rule 22(2) of the Standard Minimum Rules for the Treatment of Prisoners state:
“Sick prisoners who require specialist treatment shall be transferred to specialised
institutions or to civil hospitals.”112 In Ireland however, special psychiatric units for
prisoners do not exist within or outside prisons, and the only psychiatric hospital
that will accept prisoners is Dublin’s Central Mental Hospital (CMH). The CMH does not
have sufficient beds to match demand, and much of its infrastructure is unsatisfactory
due to insufficient capital funding. Very long waiting lists for admission to the CMH
mean that many prisoners in need of in-patient care never receive a transfer, and
other prisoners are returned to prison from the CMH before they are well. Both of
these scenarios represent a serious lack of respect for the right to proper health care
in MI Principle 20(2). Of further concern is that mentally vulnerable or ill prisoners have
been placed in isolation cells in prison, often for significant lengths of time, in conditions
which may amount to cruel, inhuman and degrading treatment, and sometimes while
awaiting transfer to the CMH.113
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36
In its 1999 report on Ireland, the European Committee for the Prevention of Torture and
Inhuman or Degrading Treatment or Punishment (CPT) commented: “A mentally ill
prisoner should be kept and cared for in a hospital facility which is adequately equipped
and possesses appropriately trained staff.” 115 In the absence of specialised psychiatric
treatment units within the prison system for those diverted to “designated centres”,
accessible alternatives in civil mental health facilities will have to be provided.
This is an issue that must be resolved immediately.116 As stated above, the only
psychiatric hospital which currently accepts patients from the prison system is
the CMH, the services of which are already overstretched. Schizophrenia Ireland
has commented thus:
THE NEGLECTED QUARTER
“The Minister (for Justice, Equality and Law Reform) should note that
existing resources of mental health services are overstretched, most
particularly, but not exclusively, in the Eastern Region where the prisoner
population is greatest. The implementation of this Bill will place an
even greater burden on these resources, and the Government
should recognise and provide for the revenue and manpower
implications accordingly.”117
The ‘Crime and Homelessness’ report advised: “Education programmes for Gardaí,
Judges, and other professionals working with the judiciary is necessary. It is essential
that those in contact with homeless adults in a law enforcement capacity should
understand more completely the particular difficulties that homeless men and women
face and what the implications of imprisonment might be on their accommodation,
family relationship or substance abuse status and on their likelihood of re-offending.”
Homeless Ex-Offenders
The CPT, in its 1999 report on Ireland, said: “In comparison with the general population,
there is a high incidence of psychiatric symptoms among prisoners.”118 A report
commissioned by the Department of Justice, Equality and Law Reform revealed
that all the mental health indicators were much worse for prisoners than the general
population.119 A 2002 international study found that these prisoners “were several times
more likely to have psychosis and major depression” and that one in seven inmates
suffers from a mental illness that could be a risk factor for suicide.120 These mental
health problems accompany prisoners on their departure from prison, and their high
mental illness prevalence indicates a distinct need in those who may find themselves
homeless upon release. Unfortunately, many are discharged to the community with
no formal discharge plans, and no arrangements for community mental health
services, or continuity of whatever limited care they had been receiving.
The ‘Crime and Homelessness’ report cautioned: “The practice of releasing prisoners
with no accommodation late on Friday evenings needs to be addressed as a matter of
urgency. Most statutory services e.g. Homeless Persons Unit, CWO (Community Welfare
Officer) etc are closed from Friday to Monday, hostel accommodation is usually assigned
to people in advance of the weekend and voluntary organisations’ supports are more
limited - people in these circumstances have no option but to sleep out.” This is a failure
to comply with the CPT’s recommendation no. 37 in its 1999 report on Ireland: that
“in relation to aftercare for prisoners, appropriate arrangements are put in place
where possible with community health care resources”.
Alcohol and Substance use
Within its prison sample, the ‘Crime and Homelessness’ study found that “those
homeless prior to and those homeless after their experience in prison cited mental ill
health, drug misuse and alcohol addiction as some of the main factors that contributed
to their homelessness and their criminal behaviour”.
This study observed: “The issue of alcohol misuse is ... important. Sixteen respondents
reported a direct link between their alcohol consumption and their offending behaviour.
Seven participants reported that their drunken behaviour led to the offence being
committed; these offences included Grievous Bodily Harm (GBH) and other types of
37
mental illness
The Homeless Preventative Strategy, published in 2002, was designed, it said, to
provide an integrated cross-departmental approach for the prevention of homelessness
in prisoners following release. Its recommendations in relation to ex-prisoners are the
establishment of a specialist unit by the Probation and Welfare Service, the creation of
transitional housing units, and a programme to ensure that prisoners who are pursuing
educational courses will be able to continue them following their release.
THE NEGLECTED QUARTER
The ‘Crime and Homelessness’ report recommended: “A variety of appropriate
accommodation ranging from emergency accommodation hostels through to
transition/supported housing through to permanent housing be that provided by
local authorities, voluntary organisations or the private rented sector is needed.”
The support of mental health and addiction services must also be available.
assault. A further 3 participants had been arrested on drunk and disorderly charges.”
It recommended: “The provision of alcohol treatment programmes should be improved.”
mental illness
38
According to WHO standards, all states should “ensure the accessibility of effective
treatment and rehabilitation services, with trained personnel, for people with hazardous
or harmful alcohol consumption and members of their families”.121 It emphasises that:
“Early recognition of problem drinking, early intervention for problem drinking,
psychosocial interventions, ... teaching new coping skills in situations associated with
a risk of drinking and relapse, family education and rehabilitation are the main strategies
proven to be effective for the treatment of alcohol-related problems and dependence.”122
Eurocare, an alliance of European agencies, has noted:
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“The Green Paper on Mental Health, published by the Government in
June 1992, commented that, in the years since the publication of
‘Planning for the Future’ in 1984, some Health Boards have developed
local alcohol/drug services and recruited addiction counsellors to work in
sector services. But it also pointed to the extremely high rate of
admission to psychiatric hospitals for alcohol-related disorders in some
Health Boards and suggested that such rates demonstrated the need to
develop alternative treatment facilities in the community.” 123
The 1999 report, ‘We have no beds’, also pointed to the need to address the “uneven
availability and responsiveness of alcohol services across the EHB area”.124, 125
Regarding drug misuse, ‘Crime and Homelessness’ noted: “The inability to maintain
addiction treatment following release from prison was also a significant problem for
respondents and this was commented on by key informant interviewees. Homelessness
made drug treatment programmes even more difficult to access, as provision is based
on catchment area and possession of a permanent address.” It advised: “There is
urgent need for a consistent and continuous Drug Policy for offenders/ex-offenders so
that prisoners can avail of drug treatment programmes while in prison and be able to
continue drug treatment programmes in the community. The detoxification, therapeutic
and rehabilitative facilities for drug users should be expanded and the links between
prison facilities and community facilities strengthened.”
39
mental illness
While substance use services are inadequate, ‘Crime and Homelessness’ points out
that the large numbers of homeless people with a dual diagnosis of mental illness and
substance misuse can be further excluded from treatment: “Substance misuse and
psychiatric services have been reluctant to manage patients with a dual diagnosis as
neither sees is as their responsibility. [...] Access criteria, whereby a person must be
drug or alcohol free before they can access mental health services further marginalizes
dual diagnosis clients.”
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In relation to drug use, the WHO 2001 report advocates: “Counselling and other
behavioural therapies are critical components of effective treatment of dependence ....
Medical detoxification is only the first stage of treatment for dependence, and by itself
does not change long-term drug use. Long-term care needs to be provided, and
comorbid psychiatric disorders treated as well, in order to decrease rates of relapse.”
It further notes the economic benefit of such an approach: “Drug dependence treatment
is cost-effective in reducing drug use (40-60%), and the associated health and social
consequences, such as HIV infection and criminal activity.126 [...] Treatment has been
shown to be less expensive than other alternatives, such as not treating dependents or
simply incarcerating them.” The lack of drug dependence services in Ireland other than
methadone maintenance treatment, for which there is a mismatch between demand
and provision, is, therefore, doubly unfortunate.
Chapter 6
mental illness
40
Additional Support Structures
Personal Advocacy
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Many homeless people with mental illness are not always in a position to assert
their rights, for a number of reasons, chiefly the nature of mental illness itself.
Family members or friends are not always best placed to act on their behalf.
“States are under an obligation to enable persons with disabilities to exercise their rights,
including their human, civil and political rights, on an equal basis with other citizens”.127
Consequently, Ireland is obliged to assist all people with mental illness in doing so, not
alone by making services available, but their use accessible. A comprehensive system
of personal advocacy for all who need it should be introduced to allow this to happen.128
Family Support
WHO notes: “families play a key role in caring for the mentally ill and in many ways
they are the primary care providers. With the gradual closure of mental hospitals in
countries with developed systems of care, responsibilities are also shifting to families.
Families can have a positive or negative impact by virtue of their understanding,
knowledge, skills and ability to care for the person affected by mental disorders.
For these reasons, an important community-based strategy is to help families to
understand the illness ....”129 ‘Planning for the Future’ also noted in 1984 that the main
burden of caring for a person with mental illness may fall on the family, and the cost
to family carers, in terms of emotional stress, can be considerable. This is particularly
so now given the widespread deficiencies in Ireland’s community-based mental health
services almost two decades after this strategy was launched, despite a commitment
at the time to fully implement its recommendations.130 In relation to families, the
strategy advised that families should be given practical assistance and advice on
dealing with the person with mental illness by the psychiatric team; the community
nurse should provide the link between the family and the psychiatric service; day care
should provide support to families where necessary; short-term respite care arranged,
and support readily available in the event of a crisis. None of these have been
satisfactorily provided. A study of carers’ views in five European countries,
including Ireland, by the European Federation of Associations of Families of
People with a Mental Illness found:
It is acknowledged that many homeless individuals will have lost contact with their
families and will have come to rely on staff in voluntary agencies for help in meeting
their many and varied needs. Acknowledgement has already been made above134 of the
type of support voluntary agencies are entitled to expect from the statutory services.
Stigma
Stigma may act as a barrier to the utilisation of available services by people with
mental illness. WHO has said: “Treatments are available, but nearly two-thirds of
people with a known mental disorder never seek help from a health professional.
Stigma, discrimination and neglect prevent care and treatment from reaching people
with mental disorders.... Where there is neglect, there is little or no understanding.
Where there is no understanding, there is neglect.”135 The stigma surrounding mental
illness has been well documented, and the public’s attitude stems from its lack of
awareness, and misconceptions about the nature of mental illness. Relative to public
41
mental illness
“Relapse of schizophrenia is often heralded by social withdrawal and verbal or physical
aggression. Family disputes leading to ejection from home or voluntary departure have
been cited on many occasions as the starting point on the path to social isolation and
homelessness for people with schizophrenia.”132 Failure to provide assistance to relatives
of people with mental illness who live at home can impact negatively on the future
stability of family relationships: “Most people who use our mental health services return
to their families on discharge from hospital. For some, difficult behaviour associated with
the illness in its acute phase may have strained family tolerance to breaking point,
making it difficult to return home.”133 For many, independent supported accommodation
will be necessary, but for others, home-based family support services and information
could facilitate in a return to the family environment.
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“For almost all ‘areas of care’ or themes, between 22% and 44% of
carers were unsatisfied or very unsatisfied. The low satisfaction found for
“Advice on how to handle specific problems” and “Information” agrees
with the findings of other studies. The findings in the areas of “Help for
the patient with preserving and regaining social functioning”, “Help in
regaining structure and routine in their life” and “Prompt assistance in
their own environment” shows the need for early intervention and
outreach work in the community.”131
perceptions about other forms of disability, a survey conducted by the National
Disability Authority revealed the following:
mental illness
42
“In general, attitudes to people with mental health disabilities were less
positive than those expressed towards people with physical disabilities.
Firstly, respondents were much less likely to mention mental health as a
disability than they were to mention physical disability. Secondly,
respondents report lower levels of comfort with people with mental
health disabilities. And, thirdly, respondents seem less sure about the
rights of people with mental health disabilities to work and to have
families.”136
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Negative public attitudes can have many consequences: “Mental illness, despite
centuries of learning is still perceived as an indulgence, a sign of weakness. This shame
is often worse than the symptoms, with people making efforts to conceal the illness from
others. Secrecy acts as an obstacle to the presentation and treatment of mental illness at
all stages. The reality of discrimination supplies an incentive to keep mental health
problems a secret.”137
While stigma may never be eliminated, it can be reduced, and it is incumbent on the
Irish state under human rights standards not alone to ensure that suitable services are
provided, but that people are assisted and enabled to access these services.
The WHO 2001 report advises: “Tackling stigma requires a multi-level approach involving
education of health professionals and workers, the closing down of psychiatric
institutions which serve to maintain and reinforce stigma, the provision of mental health
services in the community, and the implementation of legislation to protect the rights of
the mentally ill.”138
The WHO report also recommends: “Well-planned public awareness and education
campaigns can reduce stigma and discrimination, increase the use of mental health
services, and bring mental and physical health care closer to each other.”139
Misconceptions about the reality of mental illness and homeless can lead to a
hardening of public attitudes to homeless people. A recent American report has
observed in respect of that country: “Increasingly, people believe that homelessness is
caused by individual imperfections and moral failings. In particular, people with mental
illnesses and substance use disorders are seen as more blameworthy and less deserving
of compassion than homeless people who are merely ‘down on their luck.’”140 A public
education campaign should also promote awareness of the causal links between
mental illness and homelessness in order to avert such a reaction in Irish society.
The WHO Department of Mental Health and Substance Dependence is currently
carrying out a Project on Mental Health and Human Rights,142 which aims to support
countries in implementing strategies to protect and promote the human rights of people
with mental illness, by focusing specifically on the development and implementation
of mental health legislation, which, it says, represents an important means of rights
protection. WHO is currently developing a Manual on Mental Health Legislation,
which will bring together information on international norms and standards in the area
of mental health and human rights, as well as best practice evidence on mental health
law in countries throughout the world, in order to inform and assist countries in their
formulation and implementation of mental health legislation. In November 2003, WHO
also plans to hold an International Training Forum on Mental Health, Human Rights and
Legislation, which will provide countries with a unique opportunity to gain core technical
information about mental health legislation. Amnesty International strongly urges the
Irish government to participate in this important and timely process.
43
mental illness
Government policies and strategies to date have not led to comprehensive, accessible
or equitable services for homeless people with, or at risk of mental illness. The right
to the best available mental health care for all, including homeless people, should be
enshrined in national legislation. The WHO report advises: “Mental health legislation
should codify and consolidate the fundamental principles, values, goals, and objectives
of mental health policy. Such legislation is essential to guarantee that the dignity of
patients is preserved and that their fundamental rights are protected.”141 While the
Mental Health Act, 2001 is welcome in updating the law in relation to involuntary
in-patient admission and detention, Irish legislation should reflect the full range of
applicable international human rights standards.
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Mental Health Legislation
Chapter 7 Government Planning for the Future
mental illness
44
Introduction
On government responses to date, Dr Fernandez has commented:
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“Thus far, considerable emphasis has been placed on the anticipated
housing needs of the homeless, against the backdrop of a nationwide
dearth of affordable accommodation. However, specifics to safeguard
the health needs of the homeless, notably their psychological well-being
appear to be lost between the cracks which are repeatedly highlighted
as characterising the delivery of community-care services to the mentally
ill in urban centres in the Republic.”143
On the lack of real progress since the National Health Strategy was launched in 2001,
the Irish College of Psychiatrists have said: “There have been a number of Consultants’
posts approved in services for homeless people with mental illness, but these have not
been adequately resourced, and there has been no provision for full multidisciplinary
teams in this area, which are vital for such services. Services for homeless people
must be seamless and fully integrated with the local authority, and a full service cannot
be provided while working under the constraints of the present nine-to-five model. Any
adequate service for homeless people with mental illness can only be implemented with
a full team and resources. To date, the Department’s implementation of such schemes
has been piecemeal and completely inadequate.”144
Homelessness Action Plans and An Integrated Strategy
In May 2000, ‘Homelessness - An Integrated Strategy’ was launched by the
Department of the Environment and Local Government, and some of its key
recommendations include:
• Local authorities and health boards, in full partnership with voluntary bodies,
are to draw up action plans on a county-by-county basis to provide an
integrated delivery of services to homeless people by all agencies dealing
with homelessness.145
• Local authorities will be responsible for the provision of accommodation,
including emergency hostel accommodation for homeless persons and
health boards to be responsible for the provision of their in-house care
and health needs.
• A Director for homeless services in the Dublin area will be appointed by
Dublin City Council and a centre to be established for the delivery of these
services in Dublin.
• Preventative strategies, targeting at-risk groups including procedures to
be developed and implemented to prevent homelessness amongst those
leaving custodial care or health related care.
• homeless proof existing mainstream policies in the areas inter alia of
mental health, substance abuse treatment and housing; improve the
response to people on the streets with mental ill health, drug addiction
and alcohol problems.
• ensure that people with mental ill health, who are homeless or at risk of
homelessness, have access to seamless mental health treatment and support
services, appropriate to their needs, regardless of which hospital catchment
area they are in, have come from or are going to.
45
mental illness
The Dublin plan, ‘Shaping the Future’,146 was adopted in 2001, and the Homeless
Agency was established to coordinate and manage the delivery of services to people
who are homeless in Dublin. A long-term vision of this plan is stated thus: ‘By 2010
long term homelessness and the need for people to sleep rough will be eliminated’,
and by the end of 2003, the foundations for achieving its vision are to be laid.
Some of its objectives are to:
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On foot of ‘Homelessness - An Integrated Strategy’, Homeless Action Plans were
to be developed and adopted by all local authorities throughout the country to provide
an integrated delivery of services, including mental health services, to homeless people
by all agencies dealing with homelessness, and many such plans have allegedly been
developed and adopted.
mental illness
46
• ensure that people are not discharged from hospital into homelessness and to
establish protocols and procedures which will ensure that all hospital staff are
aware of the circumstances of people who are homeless and the services
available to them.
• ensure that people with a drug addiction problem who are homeless or at
risk of becoming homeless have immediate access to appropriate treatment
and support services, in their local community and to ensure continuity of
treatment if people are in prison or hospital.
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• ensure that people with problem drinking have access to residential and
community based services which will aim to minimise the harm caused
by their drinking and link them to treatment services as appropriate.
An Integrated Services Advocate for those experiencing homeless and mental health
service was appointed by the Homeless Agency to describe and document the
interface between homeless services and mental health service providers.
A joint analysis by non-governmental homeless agencies of the Action Plans found
the development of the plans “a welcome start in building a considered and
comprehensive response at local level to problems of housing and homelessness”,
and “a useful exercise in terms of consultation and beginning the process of tackling
homelessness strategically”.147 In relation to their provision for the development of
health services, including mental health care; the analysis observed: “The majority
of plans recognise the importance of health care and the particular health needs of
the homeless population, however, the language of the plans is conditional and noncommittal”. It also concluded: “The plans do achieve a relatively sophisticated
understanding of the nature and complexity of the problem, but policies for dealing
with the multiple social and health problems linked to homelessness, prevention
and the transition to permanent accommodation are weakly stated or absent.”
It also noted that the Action Plans have no statutory basis and there is no overall
reporting structure; and called for effective and transparent monitoring of the
implementation of their provisions. It suggested that an independent review of
‘Homelessness - An Integrated Strategy’ should be initiated, and be completed
before the end of 2003, to address inter alia “the inadequacies of targets, costings,
and timeframes in the local homeless action plans”.
Amnesty International also has concerns about the fate of this policy update,
given the history of ‘Planning for the Future’. Amnesty International reminds the
government that many previous reviews, reports and strategies have not been
adequately or comprehensively implemented, and urges the government to act
promptly and effectively on all recommendations that may emerge from the policy
update. Meanwhile, mental health care provision to Ireland’s homeless continues
to be deficient, and Amnesty International is concerned that this may amount at
the very least to a failure to comply with Article 12 of the ICESCR.
47
mental illness
There an urgent need for a major review of Ireland’s mental health care services,
to bring them finally into line with international best practice. The 2001 National
Health Strategy148 promised that a “national policy framework” updating ‘Planning for
the Future’ would be prepared by the Department of Health and Children, with a target
date of “Mid 2003”. Based on information received by Amnesty International from the
Department, it is anticipated that work on this policy framework will be begun this
year by an Expert Group. Amnesty is concerned that planning appropriate effective
responses for the homeless with mental illness may be seriously hampered by the lack
of government data on service provision and needs analyses. WHO offers this advice to
governments: “Authorities responsible for delivering services, treatment and care are
accountable to the consumers of the system. One important step towards achieving
accountability is to involve consumers in the creation of services, in reviewing hospital
standards, and in the development and implementation of policy and legislation.”149
Included in shaping Ireland’s future policy - particularly in view of the dearth of official
research - must be the views of all stakeholders: service users and their families,
voluntary agencies, psychiatrists, nurses, psychologists, psychotherapists, social
workers, occupational therapists, senior health board management, and representatives
from primary care. Their representative organisations should also be consulted in
advance of this policy update. To this end, Amnesty International has written to the
Minister for Health and Children outlining its position with respect to this policy update,
and has submitted to his office a joint position statement on behalf of a number of
national voluntary and professional organizations, outlining the fact that a transparent
and accountable consultation process is essential.150
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National Mental Health Policy Framework Update
Conclusion & Recommendations
mental illness
48
In Ireland, as throughout much of the world, “mental health care has simply not
received until now the level of visibility, commitment and resources that is warranted
by the magnitude of the mental health burden”.151 A heightened impetus now exists at
the international level to address the inequalities experienced by people with mental
illness, and a drive for recognition of this issue as a human rights one.
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The Irish Government has evidently failed to date to meet the requirements of best
practice and international human rights standards in its provision for the mental health
care needs of Ireland’s homeless. Mental health policy, law and resource commitments
remain worryingly inadequate; and recent government strategies are too aspirational
to guarantee effectiveness, since they lack concrete undertakings, concomitant
resource allocations or binding obligations. In this context, the importance of the
planning and delivery of the revised mental health policy framework by the
Department of Health and Children, cannot be overstated.
The recommendations made in ‘Mental Illness: the Neglected Quarter’152 apply
equally to homeless people with or at risk of mental illness, but more specific
recommendations are made here. While Amnesty International endorses many
of the more general recommendations made by the homeless agencies regarding
the root causes and consequences of homelessness, in relation to mental health
it recommends that the Irish Government take the following actions:
• In updating the national policy framework for mental health care, a
comprehensive, needs-based, service-user-led, consultative review of
the services must be undertaken, with particular emphasis on the needs
of the homeless, and its recommendations be promptly and fully implemented,
ensuring that they meet international human rights standards and best practice
in line with the World Health Organisation 2001 annual report.
• Catchment area services should be appropriately resourced and adapted, and
relevant staff trained to meet the particular needs of their homeless populations
in both in-patient and community-based settings, so they are enabled to access
a comprehensive range of services.
• Accurate data on the number and mental health needs of homeless adults
and children should be regularly compiled.
• The particularly high level of mental health care needs of Ireland’s urban
homeless population should be addressed, by ensuring a comprehensive
provision of specialised homeless mental health services, with an adequate
number of specialist in-patient acute beds, full mental health multidisciplinary
teams, and outreach services, with appropriate supports.
• Particular attention should be given to the services available to homeless
children, and those living in, and leaving, state residential care.
• An independent review of ‘Homelessness - an Integrated Strategy’ should
be undertaken to address the weaknesses evident in the development and
implementation of the homeless action plans in relation to mental health care.
• Adequate revenue funding should be ensured for voluntary homeless agencies.
• A public education and awareness programme to counter the stigma of mental
illness should be initiated, emphasising the rights of people with mental illness.
• Rights-based mental health legislation giving full effect to Ireland’s international
human rights obligations should be enacted.
• A comprehensive and adequately resourced system of personal advocacy,
to assist all people with mental illness to assert their rights in relation to
mental health care, should be provided.
49
mental illness
• An adequate range of community-based supervised and/or supported
accommodation should be provided, with appropriate mental health
supports for those capable of independent living.
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• Integrated mental health programmes should be developed for homeless people
with a dual diagnosis of mental illness, and alcohol or substance misuse and/or
intellectual disability.
• Family support and information services should be made widely available.
mental illness
50
• Garda training in mental health needs and practices with particular emphasis
on the needs of homeless people, should be introduced.
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Endnotes
2
Crowley F, ‘Mental Illness: the Neglected Quarter’,
Amnesty International (Irish Section),
Dublin (2003).
3
The report, its summary, and information on the
campaign are available at www.amnesty.ie
4
Noeleen Hartigan, Social Policy and Research
Coordinator, Simon Communities of Ireland.
Personal communication to Amnesty International,
October 2002.
5
Note 16 below.
6
UN Centre for Human Rights, The Human Right
to Adequate Housing, Fact Sheet No. 21, United
Nations, Geneva, 1995. This is a useful guide to
international human rights instruments on the right
to housing, and notes “12 different texts adopted
and proclaimed by the United Nations explicitly
recognize the right to adequate housing”.
It is available on the web at
193.194.138.190/html/menu6/2/fs21.htm
7
CESCR General comment 4, ‘The right to
adequate housing (Art.11 (1))’, 13/12/91.
8
McKeown K, ‘Mentally Ill and Homeless in
Ireland: Facing the Reality, Finding the Solutions’,
Disability Federation of Ireland (1999).
9
10
‘Analysis of the National Action Plans Social Inclusion’ (2001), available at
www.feantsa.org/key_docs/fea_docs/
naps/NAPs_analysis_EN_june_02.pdf
Adopted by General Assembly Resolution 46/119,
46 U.N. GAOR Supp. (No. 49) Annex at 188-192,
U.N. Doc.A/46/49 (1991). The MI Principles apply
to all persons with mental illness, whether or not
in in-patient psychiatric care, and to all persons
admitted to psychiatric facilities, whether or not
they are diagnosed as having a mental illness.
In this report, Amnesty International refers to the
MI Principles while recognising that they do not
enjoy universal support. It has been suggested
that they are in need of revision for a number
of reasons. Some argue that they support the
dominance of a medical model of mental illness,
by endorsing medical explanations and treatments
for ‘mental illness’; by referring to the medical
term ‘patient’ throughout, and because
medication is the only type of treatment specified.
The latter has the whole of Principle 10 dedicated
to it. These Principles have however, been utilised
by international non-governmental organisations
in their assessment of the mental health systems
of a number of countries. For a criticism of the
MI Principles, see ‘Human Rights Law in the Field
of Mental Health: a critical review’, Harding T W,
Acta Psychiatr Scand 200: 101: 24-30.
11
Although the MI Principles are a General
Assembly Resolution and therefore not legally
binding, General Comment No. 5, ‘Persons with
Disabilities’, was adopted by the UN CESCR on
9 December 1994 to outline the application of
the ICESCR to people with mental and physical
disabilities, and recognised the MI Principles
as one of the instruments to ensure respect
for the full range of human rights for persons
with disabilities.
12
CESCR, General Comment No 14 ‘The right
to the highest attainable standard of health’,
UN ESCOR, 2000, UN Doc No E/C, 12/2000/4.
13
Ibid.
14
Rule 15. Adopted by General Assembly
Resolution 48/96 in 1993.
15
General Comment No. 5, ‘Persons with
Disabilities’, UN Doc No E/C.12/1994/13 (1994).
16
‘Mental Health: New Understanding, New Hope’,
WHO, Geneva (2001).
17
See Dr Fernandez in Note 1 above, for example.
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Dr Joe Fernandez, Director of the Programme
for the Homeless, St Brendan’s Hospital, in an
advance outline of his presentation, ‘Caring for
the Homeless Mentally Ill: Status and Directions’,
for the Irish Psychiatric Association at St Patrick’s
Hospital, April 2003.
51
mental illness
1
mental illness
18
The Alcohol, Drug Abuse and Mental Health
Administration of the United States Department
of Health and Human Services in ‘A Special
Report, Assisting the Homeless’,
Intergovernmental Perspective 15 (Winter 1989).
19
Personal communication to Amnesty
International, May 2003.
20
Fernandez J, ‘The Homeless Mentally Ill’ in
the ‘Report on the Position of Psychiatry in the
Republic of Ireland, 1992’, CR 23, Royal College
of Psychiatrists, London, (1993).
21
Section 2 states: “A person shall be regarded
by a housing authority as being homeless for
the purposes of this Act if: (a) there is no
accommodation available which, in the opinion of
the authority, he, together with any other person
who normally resides with him or who might
reasonably be expected to reside with him, can
reasonably occupy or remain in occupation of, or
(b) he is living in a hospital, county home, night
shelter or other such institution, and is so living
because he has no accommodation of the kind
referred to in paragraph (a),and he is, in the
opinion of the authority, unable to provide
accommodation from his own resources.”
52
THE NEGLECTED QUARTER
22
23
Sections 175 of the Housing Act, 1996. The UK’s
new Homelessness Act, 2002 widens this
definition of homelessness, so that people leaving
state “institutions”, such as former members of
the armed forces, teenagers leaving local authority
care and young offenders released from prison categories of homelessness that were removed
by the Conservative government under the
Housing Act 1996, are included. Local authorities
in the UK have a duty under these Acts to provide
temporary accommodation to homeless
households who have a ‘priority need’. Those
who do not have a ‘priority need’ are entitled only
to the local authority’s advice and assistance.
‘Annual Housing Statistics Bulletin, 2002’,
Department of the Environment and Local
Government (2002), released in May 2003,
showed a total national count of 3773 homeless
households, comprised of 4176 adults and 1405
dependent children. This rose from 2501
individuals in 1996 and 5234 in 1999.
24
Williams J & Gorby S, ‘Counted In - The Report of
the 2002 Assessment of Homelessness in Dublin
Kildare’, ESRI/Homeless Agency (2002) found
2920 adults and 1140 children in Dublin alone.
25
Dr Fernandez suggests that the National
Psychiatric In-patient Reporting System underreports the number of homeless people with
mental illness who seek in-patient treatment,
since residents of direct access hostels are
generally not reported as being homeless.
A similar situation arises when individuals entering
hospitals give an “address of convenience” as
their own and are thereby “hidden” in official
counts of homelessness. (Personal communication
to Amnesty International, May 2003.)
26
‘Northern Ireland Housing Statistics 2000-01’,
Statistics and Research Branch, Department for
Social Development, Northern Ireland (2001).
27
Bergin E, ‘Sleeping Rough Report 2000’, Dublin
Simon, in association with Focus Ireland and
Dublin Corporation (December 2000).
28
Williams J & Gorby S, ‘Counted In - The Report
of the 2002 Assessment of Homelessness in
Dublin Kildare’, ESRI/Homeless Agency (2002).
140 individuals were identified during an actual
one-night count of those sleeping rough, revealing
a disparity with the reported figure of 312
individuals who were reportedly sleeping rough.
29
‘202 people sleeping rough in Central Dublin’,
press statement, 29th November 2000. “This
1999 count of those sleeping rough in Central
Dublin during the week of 15th-21st October 2000
represents an increase of 60% on the street count
of 8th -14th December 1997 (which found 125
persons were sleeping rough) and a 36% increase
on the street count of June 1998 (which found
149 persons were sleeping rough).”
30
Kennedy S, ‘But Where Can I Go: Homeless
Women In Dublin’, Arlen Press, Dublin (1985).
31
Williams J & O’Connor M, ‘Counted In - The
Report of the 1999 Assessment of Homelessness
in Dublin, Kildare and Wicklow’, ESRI/Homeless
Initiative, Dublin (2000).
32
‘The Mental and Physical Health and Well-being of
Homeless Families in Dublin: A Pilot Study’, Focus
‘Counted In 2002’, note 27 above.
34
The Housing Act, 1988 conferred on Local
Authorities the responsibility of conducting an
assessment of their housing need at least once
every three years. A national assessment was
carried out in 2002, note 23 above.
35
September 2002 newsletter, The Simon
Communities of Ireland, Dublin. This agency
is endeavouring to address this gap, and has
commissioned a major piece of work in mental
health assessment and data collection amongst
its clients, expected to begin in 2003.
36
Fernandez J, ‘Caring for the Homeless Mentally Ill:
Status and Directions’, seminar presentation for
the Irish Psychiatric Association at St Patrick’s
Hospital, April 2003.
37
Feeley A et al, ‘The Health of Hostel-Dwelling Men
in Dublin’, Royal College of Surgeons in Ireland &
Eastern Health Board (March 2000), found that 64
per cent of the survey population were suffering
from some form of mental health condition.
38
‘The Homeless Mentally Ill - discussion
document’, Appendix A, ‘Cluain Mhuire Adult
Mental Health Service Proposal: The Homeless
Mentally Ill’, Barry Dr S, Cluain Mhuire Adult
Mental Health Service, Dublin (2002).
39
‘Caring for the Homeless Mentally Ill: Status
and Directions’, seminar presentation for the
Irish Psychiatric Association, St Patrick’s Hospital,
April 2003.
Fernandez J, ‘The Homeless Mentally Ill: Aspects
of Violence’, paper presented at the Symposium
on ‘Aspects of Violence: The Care of the Disturbed
Mentally Ill’, Dublin, Ireland (1996).
41
Note 16 above.
42
Holohan T & Holohan W, ‘Health and
Homelessness in Dublin’, Irish Medical
Journal Volume 93 No 2, March/April 2000.
43
Note 31 above.
44
‘Mentally Ill and Homeless in Ireland: Facing
the Reality, Finding the Solutions’, note 8 above,
based on an estimated average incidence of
mental illness among the population of between
25 and 30 per cent.
45
Note 42 above.
46
See Focus Ireland pilot study, note 32 above, which
found only 28.6 per cent ‘psychiatric caseness’ in
its sample. However, it noted:
“The families involved had achieved some degree
of accommodation stability in the family transition
unit of Focus Ireland. This contrasted to some
extent with [a recent study conducted in England]
where the families assessed, were placed in
short-term accommodation hostels. In that study
they were assessed within two weeks of entering
the hostels whereas in the Dublin pilot study the
majority of the mothers interviewed had been in
their accommodation for a number of months. ...
[and they] reported a considerable improvement
in their own mental health since obtaining some
degree of stability of accommodation.”
47
For example, in the UK, see Adams C, Pantelis C,
Duke P & Barnes T, ‘Psychopathology, Social
Cognitive Functioning in a Hostel for Homeless
Women’ (1996), Br J Psychiatry 168:82-86,
and in the US, Bassuk E L, Rubin L, & Lauriat A S,
‘Characteristics of Sheltered Homeless Families’
(1986), Am J Public Health 76(9): 1097-1101.
48
Note 32 above.
49
Note 16 above.
THE NEGLECTED QUARTER
33
40
53
mental illness
Ireland, the Mater Hospital and the Northern Area
Health Board. This pilot study came about as a
result of concern within three agencies - the
Department of Child and Family Psychiatry at the
Mater Hospital in Dublin; the Housing Division of
Focus Ireland and the Area Medical Services,
Community Care Area 6, of the Northern Area
Health Board, about the effects of homelessness
on families and their children, the lack of adequate
support services and how the mental health
of parents impacts on children, especially in
homeless families. This pilot study was carried
out in Dublin through the collaboration of these
three agencies.
50
mental illness
54
McCrum J, ‘The Face of Older Homelessness’,
Simon Community Northern Ireland (2002).
In Northern Ireland, the Housing Act 1988
provides a positive duty on the Housing Executive
to provide temporary accommodation to a person
homeless and with “priority need”, the definition
of which includes mental disability.
51
Ibid.
52
‘Simon has serious concerns for state funding
of homeless services’, Simon Communities of
Ireland, press release, 5 November 2002.
THE NEGLECTED QUARTER
53
Note above.
54
Houghton F T & Hickey C, ‘Focussing on B&Bs:
The Unacceptable Growth of Emergency B&B
Placement in Dublin’, Focus Ireland, Dublin (2000)
Recent government figures show €19.5m spent
on B&B accommodation in 2002.
55
Personal communication to Amnesty International,
May 2003.
56
‘The Psychiatric Services: Planning for the Future’,
The Stationery Office, Government Publiciations,
Dublin (1984).
MI Principle 9(1), note 10 above.
65
Note 62 above.
66
‘Schizophrenia Ireland’s Response to the Inspector
of Mental Hospitals Report 2001’ (2002).
67
‘Health and Homelessness in Dublin’,
note 42 above, found that 45 per cent of the 502
homeless people surveyed did not have a medical
card even though almost half saw themselves as
being in poor general health.
68
Dr Fernandez, personal communication to
Amnesty International, May 2003.
69
‘Health Strategy 2001: Submission by the
Simon Community of Ireland to the Department
of Health on its review of the Health Service’,
Simon Communities of Ireland .
70
Fernandez J, ‘On Planning and Expanding a
Service for the Homeless Mentally Ill’, report
submitted to the Programme Manager, Special
Hospital Care, Eastern Health Board, 1993.
71
Note 38 above.
72
‘Shaping the Future’, note 144 below, says:
“Homelessness is a persistent and growing
problem in Dublin. About three quarters of all
people who are homeless in the country are
in the Dublin area, 95% of them in the city.”
73
Fernandez J, ‘Who cares for the NFA’s’, in
‘Living on Fresh Air’, Simon Community
National Office, Dublin (1983).
74
Note 63 above.
75
The UK mental health organisation, Mind,
published a document entitled ‘Mind’s Model
of a 24 Hour Crisis Service’ (Cobb A, Mind
Publications, (1995)), which provides an example
of what a model crisis service might look like.
See also Sayce, Christie, Cobb and Slade, ‘Users’
Perspective on Emergency Needs’, in Phelan Dr M,
Strathdee Dr G & Thornicroft Dr G (Eds),
‘Emergency Mental Health Services in the
Community’, Cambridge University press (1994).
76
Note 62 above.
32
57
Simon Community National Office (1989).
58
Note 16 above.
59
Harvey B, ‘Homelessness and Mental Health.
Policies and Services in an Irish and European
Context’, Homelessness and Mental Health
Action Group (1998).
60
64
Fernandez J, ‘Homelessness: an Irish perspective’,
in Bhugra D (ed), ‘Homelessness and Mental
Health’, Cambridge University Press (1996).
61
Dr Fernandez, personal communication to
Amnesty International, May 2003.
62
Keogh F, Roche A & Walsh D, ‘We Have No Beds:
An Enquiry into the Availability and Use of Acute
Psychiatric Beds in the Eastern Health Board
Region’, Health Research Board, Department
of Health and Children (1999).
63
‘Report of the Inspector of Mental Hospitals
for the year ending 31st December 2001’,
Department of Health and Children, Government
Publications Sales Office, (2002).
78
Ibid.
79
Ibid.
80
Ibid.
81
Ibid.
82
Simon Communities, note 69 above.
83
In relation to discharge from psychiatric care,
the Simon Communities note: “...homeless
services claim that they are being used as a
‘dumping ground’ by the mental health services,
who send people presenting with mental illness
to homeless hostels because the person and (it is
claimed) the health service have no other option.
However the Department of Health counters that
from research they completed in 1992 tracing
patients discharged from Mental Institutions, none
of those discharged became homeless. The issue
therefore may be that many people which the
Psychiatric service classifies as having behavioural
difficulties but not mental illness and therefore not
part of their responsibility are finding their way
into the ‘homeless net’ while previously they
would have been housed in Mental Institutions.”
(Bergin E, ‘Policy Audit of Recent Developments
in the area of Mental Health and Homelessness’,
Simon Communities of Ireland, (2002).)
84
‘“Still Waiting for the Future”, Simon Community’s
response to the Government’s Green Paper on
Mental Health’ (1992).
85
Simon Communities, note 69 above. It continues:
“For example, during 2000, in Dublin Simon’s
shelter a total of 47 people or 7 per cent of all
people accommodated came directly from
hospital.”
86
‘CentreCare Annual Report 2001’, Dublin.
87
‘Homeless Preventative Strategy’, published by
the Cross Department Team on Homelessness
in February 2002, Chapter 4 of which deals with
people leaving mental health facilities.
88
‘Guidelines on good practice and quality assurance
in mental health services’, Department of Health
and Children (1998).
89
Circular 5/87: ‘Arrangements for Discharge from
Hospital and Aftercare of Homeless Persons’,
Department of Health and Children (1987).
90
The Inspector of Mental Hospitals for 2001, note 63
above, also observed that the development of
community-based accommodation is somewhat
uneven throughout the country.
91
A recent report describes the forms of supported
housing that exist throughout Europe: community
lodgings, group homes, protected apartments,
sheltered housing, transitional accommodation,
and supported housing. It notes that a distinction
is increasingly being drawn between ‘supported
housing’ and ‘support in housing’. The former,
it says, describes an approach where a planned
programme of support is provided in a particular
physical space (which may even have been
purpose built); the support is centred on the
accommodation which people move through.
The latter term, it suggests, indicates a situation
where people live in ordinary housing (selfcontained or shared) in the community and
support is provided (either permanently or
temporarily) as required by tenants. The preferred
approach is perceived by most to be in the form of
‘support in housing’. (Edgar B, Doherty J & MinaCoull A, ‘Support and Housing in Europe - Tackling
social exclusion in the European Union’, Joint
Centre for Scottish Housing Research, University
of Dundee and University of St Andrews (2000)).
92
Note 38 above.
93
Note 69 above.
94
Bergin E, ‘Policy Audit of Recent Developments
in the area of Mental Health and Homelessness’,
Simon Communities of Ireland, (2002).
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Fernandez J, ‘Dual-diagnosis, dangerousness
and dereliction’, paper presented at the Fourth
European Seminar on Mental Health and Social
Exclusion, Madrid, Spain, April 1997.
55
mental illness
77
95
mental illness
96
56
Culhane D P, Metraux S & Hadley T, ‘Public
Service Reductions Associated with Placement
of Homeless Persons with Severe Mental Illness
in Supportive Housing’, Housing Policy Debate 13,
1 (2002): 107-163. Considerable cost savings
were also found due to the decreased use of
these services.
One staff member of an emergency shelter
spoke to Amnesty International of the particular
demands on an already overburdened service of
having a resident with severe mental illness for
a number of months, despite a commitment from
the local mental health service that this placement
would only be a temporary measure while more
suitable accommodation was arranged.
THE NEGLECTED QUARTER
97
Mary Higgins, Director of the Homeless Agency,
Homeless Agency press release, 14 April 2002.
98
Article 23(2).
99
Ivan Mahony, Section Manager, Young Person’s
Services, Focus Ireland, in ‘No homes to go to’,
Poverty Today, March/April 2000, No. 46, states:
“The current state of child homelessness in
Ireland is nothing short of a national disgrace.
Section 5 of the Child Care Act 1991 conferred
a legal duty on health boards to provide
accommodation for all homeless children in
their area. Yet the number of homeless children
re-referred (i.e. those who remain homeless for
periods of time) through both health boards and
non-statutory services is staggering.”
100
101
Kelleher P, Kelleher C & Corbett M, ‘Left Out on
Their Own: Young People Leaving Care in Ireland’
(2000), Focus Ireland.
The UN Committee on the Rights of the Child
recommends: “the system of data collection
and development of indicators be adjusted to
include all children up to the age of 18, with a
view to incorporating all the areas covered by
the Convention ... with specific emphasis on
vulnerable children and children in especially
difficult circumstances. Adequate disaggregated
data should be gathered and analysed in order
to monitor and assess progress achieved in the
realisation of children’s rights and to help define
policies to be adopted to strengthen the
implementation of the provisions of the
Convention.” (Concluding observations of the
Committee on the Rights of the Child: Ireland,
04/02/98, CRC/C/15/Add.85.)
102
Note 100 above.
103
‘The Health of our Children’, Second Annual
Report of the Chief Medical Officer, Department
of Health and Children (2001).
104
“Approaches to the promotion and development
of sound mental health for children, and the
identification and treatment of psychological
and psychiatric disorders, have been patchy,
uncoordinated and underresourced.” (Ibid.)
See Chapter 6 of ‘Mental Illness: The Neglected
Quarter’ note 2 above for Amnesty International’s
general concerns and recommendations in
relation to mental health care for children
and adolescents.
105
Note 101 above..
106
Hickey C, ‘Crime and Homelessness’,
Focus Ireland & PACE, Dublin (2002).
107
The report suggests: “Inclusion of prisoners
who are homeless in homeless statistics is
essential so as to provide a clearer picture
of both the homeless and prisoner populations
for planning purposes.”
108
O’Mahoney P, ‘Crime and Punishment in Ireland’,
Roundhall, Dublin, (1993) and O’Mahoney P,
‘Mountjoy Prison: A Sociological and
Criminological Profile’, Stationery Office, Dublin
(1997).
109
Prisoners and Homelessness, PACE, Dublin,
(2002), unpublished and conducted for internal
information purposes.
110
“The criminal behaviour of those who are
homeless is often characterised by the survivalist
nature of the crimes they commit e.g. begging,
shop lifting and other types of larceny and by
crime carried out to escape the physical reality
of homelessness e.g. drug and alcohol related
offences.” International literature identified in
this report indicates a very high level of arrest
and imprisonment of homeless people. It is not
‘Report of the Group to Review the Structure
and Organisation of Prison Health Care
Services’ (2001).
112
Adopted by the First United Nations Congress
on the Prevention of Crime and the Treatment of
Offenders, held at Geneva in 1955, and approved
by the Economic and Social Council by its
resolution 663 C (XXIV) of 31 July 1957 and
2076 (LXII) of 13 May 1977.
113
Amnesty International, in a letter to the Minister
for Justice in August 2001 in relation to an Irish
report (‘Out of Mind, Out of Sight: Report on
Confinement of Mentally Ill Prisoners in Ireland’,
Bresnihan Dr V, Irish Penal Reform Trust (2001)),
expressed its concern at this practice as a
substitute for medical or psychological care,
which may constitute a violation of international
standards for humane detention. Amnesty
International welcomes a commitment given
by the Minister for Justice, Equality and Law
Reform in a letter to the IPRT that padded cells
will be replaced by safety observation cells that
will fully meet the needs and respect the dignity
of the prisoner. Amnesty International urges that
this instruction be complied with immediately,
and that the alternative meet the requirements
of international best practice and human rights
standards. In tandem, vigilance in the operation,
monitoring, and recording of use of observation
cells must be ensured so as to avoid a repeat
of the practices documented by the IPRT.
Amnesty International also welcomes the
Minister’s statement in this letter that“ no
mentally ill prisoner who is awaiting transfer
to the Central Mental Hospital will be held in a
padded cell, unless this is unavoidably necessary
as an immediate and time-limited measure for
the protection of the prisoner from harm”.
Amnesty International is nevertheless concerned
that, given the continuing absence of suitable
114
Note 16 above.
115
Report to the Irish Government on the visit to
Ireland carried out by the European Committee
for the Prevention of Torture and Inhuman or
Degrading Treatment or Punishment (CPT) from
31 August to 9 September 1998, CPT/Inf (99)
15 [EN], Publication Date: 17 December 1999.
116
Some argue that civil mental hospitals are the
better option. The CPT simply said in its 1999
report on Ireland: “That facility could be a civil
mental hospital or a specially equipped
psychiatric facility within the prison system.”
117
‘Position Paper of SI on the Criminal Law
(Insanity) Bill 2002’, Schizophrenia Ireland,
February 2003.
118
Note 115 above.
119
‘General Healthcare Study of the Irish Prisoner
Population’, Centre for Health Promotion Studies,
Department of Health Promotion, National
University of Ireland, Galway (2000). It found
that 48 per cent of male and 75 per cent of
female prisoners were classed at ‘case1 level’
using the GHQ-12 instrument.
120
‘Serious mental disorder in 23,000 prisoners:
a systematic review of 62 surveys’, Fazel S
& Danesh J, Lancet 2002; 359: 545-50.
121
WHO European Charter on Alcohol, drawn up at
the European Ministerial Conference on Health,
Society and Alcohol hosted by WHO, Paris,
France, December 1995.
122
Note 16 above.
57
mental illness
111
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alternatives for prisoners with mental illness
within the prisons, and as the Minister’s edict
is similar to that contained in the Rules for
Government of Prisons, 1947 (S.I. number 320
of 1947) under which the practice in question
operated, this grave situation may continue.
Consequently, special psychiatric facilities and
treatment for prisoners must be provided as
a matter of the utmost urgency.
known if homeless offenders are more likely to
be sent to prison than offenders with homes
for the commission of the same crime, but the
report’s author suggests that this might merit
further study.
123
mental illness
58
THE NEGLECTED QUARTER
124
125
126
‘National Alcohol Policy Ireland’, Eurocare Advocacy for the Prevention of Alcohol
Related Harm in European, available at
www.eurocare.org/profiles/irelandsect2.
It also notes the lack of research in this area:
“The dearth of alcohol research in Ireland, with
youth research the exception, means that we
over-rely on international research. We continue
to need clarification on important alcohol related
issues such as the economic, social and
psychological causes and effects of alcohol
consumption, the extent of alcohol dependence
and treatment effectiveness. We also have many
unanswered questions in relation to the most
effective alcohol prevention models in different
alcohol cultures with a group and settings
approach. Alcohol research must be improved
to provide important measures for public health
assessment and to allow for both effective and
efficient use of resources.”
Note 62 above. The Inspector of Mental Hospital’s
report, note 63 above, cautions:
“...’detoxification’ from alcohol toxicity is
inappropriate and, in severe toxicity, an
unsafe procedure, in a psychiatric setting.
Where toxicity is severe, with the likelihood
of severe withdrawal symptoms and possible
neurological complications, the safest place
for such persons is on general medical wards,
not in an isolated psychiatric setting.”
Conversely, the report of the Inspector of
Mental Hospitals for 2001 refers to “the
extensive provision of community-based
alcohol treatment services”.
‘Crime and Homeless’ found: “Thirty-seven
respondents (out of 46) reported that their
criminal behaviour was directly linked with
their drug misuse, and 35 of them (95 per cent)
reported that they had committed their offence
in order to finance their drug habit. The life
experiences reported by the respondents were
echoed in the discussions with professionals
working in the welfare and prison services and
voluntary organisations. All of these recognised
drugs as a major factor in offending behaviour.”
127
Rule 15 of the UN Standard Rules on the
Equalisation of Opportunities for Persons
with Disabilities.
128
For a comprehensive analysis of personal
advocacy, its various models, and how it
operates in different countries, see ‘Advocacy:
A Rights Issue’, Forum of People with Disabilities,
Ireland (2001).
129
Note 16 above.
130
See Chapter 3 of ‘Mental Illness:
The Neglected Quarter”, note 2 above.
131
‘Breaking the Silence: Carers’ views on the
help given during the first episode of psychosis,
A European perspective’, European Federation
of Associations of Families of People with a
Mental Illness, Madrid, October 2001.
132
Note 38 above.
133
‘Tumbling down the ladder’, Martin Rogan,
Director of Mental Health Services, South
Western Area Health Board in ‘CornerStone,
The magazine of the Homeless Agency’, issue
no. 11, April 2002, The Homeless Agency, Dublin.
134
Support for Voluntary Agencies.
135
‘The World Health Report 2001: Mental Disorders
Affect One In Four People, Treatment available
but not being used’, WHO Press Release,
WHO/42.
136
‘Attitudes to Disability: Preliminary Findings of a
survey commissioned by the National Disability
Authority’, NDA Research Unit & Research and
Evaluation Services, October 2001.
137
Irish Psychiatry Online, the web page of the
Irish College of Psychiatrists:
www.irishpsychiatry.com/public.html#2.
138
Note 16 above.
Beatty C A & Haggard Loretta K, ‘Legal Remedies
to Address Discrimination Against People Who
Are Homeless and Have Mental Illnesses’,
National Resource Centre on Homelessness
and Mental Illness, Policy Research Associates
Inc, Delmar, New York (1998).
141
Note 16 above.
142
For information,
see www.who.int/hhr/mental_health
143
Note 1 above.
144
‘Quality and Fairness: A Health System for You,
Health Strategy 2002 - A Year On, The lack of
implementation of the Health Strategy on Mental
Health’, Irish College of Psychiatrists (2003).
145
“Local homeless persons centres will be
established jointly by local authorities and health
boards, in consultation with the voluntary bodies,
throughout the country. The service provided
will be enlarged to involve a full assessment of
homeless persons’ needs and to refer persons
to other health and welfare services.” Arising out
of this, some local authorities plan a dedicated
service delivery system to people out of home a one-stop-shop. Others see a mixed type of
service delivery with the development of a
dedicated centre or unit for advice and some
direct service provision but with other services
delivered through a number of different sources
e.g. other statutory service providers, voluntary
organisations and community groups.
146
‘Shaping the Future: an action plan on
homelessness in Dublin 2001-2003’ (2001).
147
Punch M et al, ‘Housing Access for All? An
Analysis of Housing Strategies and Homeless
Action Plans’, Focus Ireland, Simon Community,
St. Vincent de Paul, Threshold, Dublin, (2002).
148
‘Quality and Fairness - A Health System for You’,
Department of Health and Children (2001).
149
Note 16 above.
150
‘Joint NGO Position Statement on the Planned
Review of Mental Health Policy’, May 2003.
151
‘Mental Health: A Call for Action by World Health
Ministers’, Ministerial Roundtables 2001, 54th
World Health Assembly, Geneva,
WHO/NMH/MSD/WHA/01.1.
152
Note 2 above.
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140
Ibid. It points to the “Open the doors” project
launched by the World Psychiatric Association
in 1999, the first-ever global programme against
stigma and discrimination associated with
schizophrenia, which aims to increase
awareness and knowledge about the nature of
schizophrenia and treatment options; to improve
public attitudes to people who have or have had
schizophrenia and their families; and to generate
action to eliminate stigma, discrimination and
prejudice. The WPA has produced a step-by-step
guide to developing an anti-stigma programme,
and reports on the experience of countries that
have undertaken the programme, as well as
collecting information from around the world
on other anti-stigma efforts. The materials have
been put to trial use in Austria, Canada, China,
Egypt, Germany, Greece, India, Italy and Spain.
59
mental illness
139
mental illness
60
THE NEGLECTED QUARTER